LIBRARY OF CONGRESS. 



Shelf J3L& & 



UNITED STATES OF AMERICA 





LECTU RES 



ON THE 



PRINCIPLES AND PRACTICE 



OF 



MEDICINE. 



DELIVERED IN 



CHICAGO MEDICAL COLLEGE, MEDICAL DEPARTMENT OF THE 
NORTHWESTERN UNIVERSITY, 



J 
I i BY 



/ 

NATHAN SMITH DAVIS, A.M., M.D., LL.D., 

DEAN OF THE FACULTY AND PROFESSOR OF PRINCIPIES AND PRACTICE OF MEDICINE AND CLINICAL MEDICINE, IN CHICAGO 
MEDICAL COLLEGE; SENIOR PHYSICIAN TO THE MERCY HOSPITAL-, CHICAGO; MEMBER AND EX-PRESIDENT OF 
THE AMERICAN MEDICAL ASSOCIATION, OF THE ILLINOIS STATE MEDICAL SOCIETY AND OF THE CHICAGO MEDI- 
CAL SOCIETY ; MEMBER OF THE ILLINOIS STATE MICROSCOPICAL SOCIETY, CHICAGO ACADEMY OF 
SCIENCES, AMERICAN PUBLIC HEALTH ASSOCIATION; HONORARY MEMBER OF THE NEW 
YORK. ACADEMY OF MEDICINE, AND OF THE COLLEGE OF PHYSICIANS, 
PHILADELPHIA. ETC. 




CHICAGO: 

JANSEN, McCLUEG & CO, 
1884. 



^ 



COPYRIGHT, 

BY JAXSEN, MCCLUKG, & CO., 

A. D. 1884. 



Stereotyped and Printed 

by the 

Chicago Legal News Company. 



PREFACE. 



The lectures comprised in this volume, embrace substantially the course 
of instruction on the principles and practice of medicine given by me 
in the Medical Department of the Northwestern University, better known 
as the Chicago Medical College. My method of lecturing being entirely 
extempore, the lectures comprising the first half of the volume, under the 
heads of Principles of Medicine and Acute General Diseases, were origi- 
nally reported by Leander Stone, stenographer; and those comprising the 
rest of the volume, by James E. Henderson, M. D. All the manuscript 
has been fully revised, and not a small portion re- written by me in the 
midst of so great an amount of other professional and literary work, that 
it has been impossible to bestow upon it sufficient minuteness of attention 
to avoid all errors in typography and modes of expression. 

Three motives have combined to induce me to endure the labor of pre- 
paring these lectures, and superintending their publication at the present 
time. One was to comply with the expressed wish of a large number of 
practitioners who have honored me with their presence in the lecture room 
of the college and the clinical wards of the hospital, during some part of 
the thirty-five years that I have been engaged uninterruptedly in the 
work of teaching medicine. Another was the desire to place within the 
reach of medical students, a work on practice which embodies in its 
text the metric system of weights and measures, and thereby greatly 
facilitate the change which has been declared by nearly all our social pro- 
fessional organizations to be desirable. This change from the apotheca- 
ries' system to the metric, has progressed just far enough to give us 
throughout our current medical literature a most undesirable mixture of 
both systems. To render the transition complete in a brief period of time, 
it is only necessary that the authors of practical works should incorporate 
the metric system into the text of their volumes. To prevent embarrass- 
ment on the part of the great body of practitioners who have already been 
educated exclusively in the apothecaries' system, the latter might be given 
as equivalents in brackets, as has been done throughout all the lectures 
embraced in this volume. 

The third motive was a desire to place on record, accessible to the 
profession generally, those views and modes of practice developed in 
my own mind, as a result of fifty years of constant devotion to the study 
and practice of the healing art, on a field amply sufficient for both scientific 
study and direct clinical observation. 

N. S. DAVIS. 

65 Randolph St., Chicago, Sept. 8, 1884. 

(i) 



i 



CONTENTS. 



PAET I, 

ELEMENTARY CONSIDERATIONS OR PRINCIPLES OP MEDICINE. 

LECTURE I. 

PAGE 

Health. Definition of Disease. A Knowledge of what Constitutes Health necessary 
to a clear conception of Disease. Analysis of Health. The Fluids. The 
Solids. Their Properties and Relations. Elementary Properties. Ele- 
mentary Functions. Tabular Statement 11 

LECTURE II. 

Disease. Analysis of Disease. Its Elementary Forms. Changes in the Blood. 
Changes in the Organized Tissues. Functional and Structural Disease. Tab- 
ular Statement. Why all Attempts to Build up Systems or Theories of 
Medicine, Founded on some supposed Universal Principle of Morbid Action, 
have failed 19 

LECTURE IIL 

General Processes and Complex Functions. Their Relations to Each Other in 
Health and Disease. What Constitutes Nature. The Efforts of Nature. — 
44 Vis Medicatrix Naturae." 25 

LECTURE IV. 

Medicines. What are Medicines? What the Distinctions Between Food and 
Medicines. Their Classification for Therapeutic Purposes. Etiology. . . 33 

LECTURE V. 

Examination of the Sick. By Inspection, Oral Questions, Palpation or Touch, 
Instrumental Aid. The Principles of Diagnosis. Therapeutic Methods, 
etc. 40 



PART II 



CONSIDERATION OF INDIVIDUAL DISEASES OR PRACTICE OF 

MEDICINE. 



LECTURE VI. 

Classification of Disease. Objects to be attained. Extended Nosological Arrange- 
ments of Little Practical Value. The Simplest Classification the Best. . 48 

(iii) 



IV CONTENTS. 



GENERAL DISEASES. 



LECTURE VII. 

PVGE 

General Pathology of Fevers. Ancient and Modern Views Compared. The 
Unity or Oneness of All Fevers, and Their Diversity. Pathological Conditions 
Common to them all 52 

LECTURE VIII. 

Continued Fevers : Their General Characteristics — Individual Members of the class 
— Divisible into Three groups with Distinct Etiological Characteristics — 
First Group — Simple Continued, Irritative or Transient Fever or Febricula. . 61 

LECTURE IX. 

Influenza and Dengue : Influenza— Its History, Symptoms, Prognosis, Pathological 
Anatomy, Etiology, Diagnosis and Treatment. Dengue — Its History, Symp- 
toms, Prognosis, Etiology, Diagnosis and Treatment 69 

LECTURE X. 

Typhoid Fever: Its History and Etiology 77 

LECTURE XL 

Typhoid Fever: Its Symptoms, Diagnosis, and Prognosis. . . . .86 

LECTURE XII. 
Typhoid Fever: Its Pathology and Pathological Anatomy. . ► . .94 

LECTURE XIII. 
Typhoid Fever: Its Treatment 102 

LECTURE XIV. 

Typhoid Fever: Its Treatment, Complications, Intestinal Hemorrhage, Per- 
foration of the Intestines, Sequelae. Ill 

LECTURE XV. 

Typhus Fever and Plague : Their History, Causes, Symptoms, Diagnosis, Prog- 
nosis, Special Pathology, Pathological Anatomy, Treatment and Prophylaxis. 122 

LECTURE XVI. 

Relapsing Fever: Its History, Causes, Symptoms, Diagnosis, Prognosis, Special 
Pathology, Pathological Anatomy, Treatment and Prophylaxis. . . 131 

LECTURE XVII. 

Yellow Fever: Its History, Causes, Symptoms, Diagnosis, Prognosis, Patholog- 
ical Anatomy, Special Pathology, Treatment and Prophylaxis. . . .139 

LECTURE XVIII. 

Erysipelas: Its History, Causes, Symptoms, Diagnosis, Prognosis, Pathological 

Anatomy, Special Pathology, Treatment and Prophylaxis 154 



CONTENTS. V 



LECTURE XIX. 



PAGE 



Diphtheria: Its History, Causes, Symptoms, Diagnosis, Prognosis, Pathology, 
Treatment, Convalescence, Prophylaxis and Sequelae 163 

LECTURE XX. 
Periodical Fevers: History, Causes, Varieties 178 

LECTURE XXI. 

Intermittent and Remittent Fever: Symptoms, Pathological Anatomy, Diagnosis, 

Prognosis, Treatment 186 

LECTURE XXII. 

Pernicious Fever; Hemorrhagic Malarial Fever; Typho-Malarial: Symptoms, 

Pathology and Treatment * 196 

LECTURE XXIII. 

Eruptive Fevers: History, Causes, Pathology, Anatomical Characteristics. Gen- 
eral Principles of Treatment 204 

LECTURE XXIV. 

Variola, Varioloid and Vaccinia: Symptoms, Diagnosis, Prognosis, Special Treat- 
ment and Prophylaxis 213 

LECTURE XXV. 

Varicella, Sudamina and Scarlatina: History, Symptoms, Diagnosis, Prognosis, 
Pathological Changes, Complications and Sequelae, Treatment and Prophy- 
laxis 225 

LECTURE XXVI. 

Rubeola, Rotheln, Roseola, Pertussis, Mumps: History, Causes, Symptoms, 

Diagnosis, Prognosis, Pathological Anatomy, Treatment and Sequelae. . 226 

LECTURE XXVII. 

Chronic General Diseases: Diseases Included Under this Head— Circumstances 
Common to Them All — General Etiological and Pathological Considerations 
Concerning Them — General Treatment. 249 

LECTURE XXVIII. 

Scrofula: Adenitis — Symptoms, Pathology, Treatment. Scrofu 1 ous Inflamma- 
tion of Mucous Membranes, etc. 253 

LECTURE XXIX. 

Leucocythaemia, Pseudo-leucocythsemia, Pernicious Anaemia, Addison's Disease: 
History, Causes, Symptoms, Pathology, Diagnosis, Prognosis, Treatment. . 267 

LECTURE XXX. 

Carcinoma, Constitutional Syphilis: Varieties, Development, Diagnosis, Prognosis 
and Treatment 278 



VI CONTENTS. 



LECTURE XXXI. 

PAGE 

Rheumatism: Etiology, Symptoms, Acute, Sub-acute, Chronic; Diagnosis, 
Prognosis, Pathology, Treatment 291 

LECTURE XXXII. 

Gout, Arthritis Deformans: History, Causes, Symptom', Morbid Anatomy, Di- 
agnosis, Prognosis, Treatment 302 



LOCAL DISEASES. 



LECTURE XXXIII. 
Inflammation: Pathology, Results or Terminations of Inflammation, Treatment. 313 

LECTURE XXXIV. 

Pachymeningitis, Meningitis, Cerebritis: Pachymeningitis — Symptoms, Diagno- 
sis, Pathology, Prognosis, Treatment. Meningitis — Tubercular Meningitis. 
Cerebritis — Cerebral Sclerosis, Symptoms 321 

LECTURE XXXV. 

Meningitis, Cerebritis and Sclerosis: Pathology, Diagnosis, Prognosis, Treat- 
ment and Convalescence 331 

LECTURE XXXVI. 

Cerebro-Spinal Meningitis — Sporadic and Epidemic: Sporadic — Symptoms, Di- 
agnosis, Prognosis, Treatment. Epidemic — History, Causes, Symptoms, 
Morbid Anatomy, Diagnosis, Prognosis 339 

LECTURE XXXVII. 

Epidemic Cerebro-Spinal Meningitis, Spinal Meningitis, Myelitis: Epidemic 
Cerebro-Spinal — Treatment and Sequelae. Spinal Meningitis and Myelitis — 
Etiology, Symptoms, Morbid Anatomy, Diagnosis, Prognosis, Treatment. 350 

LECTURE XXXVIII. 

Chronic Spinal Meningitis, Myelitis or Spinal Sclerosis: Symptoms, Morbid 

Anatomy, Diagnosis, Prognosis, Treatment. . .... 361 

LECTURE XXXIX. 

Inflammation of Respiratory Organs — Several Structures included under this 
Head — Historical and Etiological Considerations — Acute and Chronic In- 
flammation of the Naso-Pharyngeal Membrane: Symptoms, Diagnosis, 
Prognosis, and Treatment. 369 

LECTURE XL. 

Laryngo-Tracheitis : Varieties, Causes, Pathology, Symptoms, Diagnosis, Treat- 
ment 381 



CONTENTS. Vll 



LECTURE XLI. 

PAGB 

Bronchitis — Acute and Chronic: History, Etiology, Symptoms, Pathology. . 393 

LECTURE XLII. 
Bronchitis, and Asthmatic Bronchitis: Prognosis, Treatment, Prophylaxis. 403 

LECTURE XLIII. 

Pneumonia: History, Etiology, Symptoms, Varieties, Pathology, Diagnosis, 

Prognosis 416 

LECTURE XLIV. 

Pneumonia: Treatment. Chronic Pneumonia: History, Symptoms, Treat- 
ment 426 

LECTURE XLV. 

Pleuritis — Acute and Chronic: Symptoms, Morbid Anatomy, Prognosis, Diag- 
nosis, Treatment. 437 

LECTURE XLVI. 

Phthisis Pulmonalis: Varieties, Symptoms, Anatomical Changes. . . . 450 

LECTURE XLVII. 

Phthisis Pulmonalis: Diagnosis, Prognosis. Treatment 461 

LECTURE XLVIII. 

Pericarditis: Symptoms, Pathology, Diagnosis, Prognosis, Treatment. . 471 

LECTURE XLIX. 

Myo- and Endocarditis : Symptoms, Diagnosis, Prognosis, Treatment. Inflam- 
mation of the Aorta. Acute Ulcerative Endocarditis. . . . . . 478 

LECTURE L. 
Stomatitis: Varieties, Symptoms, Diagnosis, Treatment. .... 489 

LECTURE LI. 

Glossitis, Tonsilitis, Oesophagitis, Gastritis: Symptoms, Diagnosis and Treat- 
ment 505 

LECTURE LIT. 

Gastritis, Duodenitis, Duodeno- Hepatitis: Symptoms, Diagnosis, Prognosis 

and Treatment 516 

LECTURE LIII. 

Enteritis, Typhlitis, Perityphlitis: Causes, Symptoms, Pathology, Diagnosis, 

Prognosis and Treatment 534 



VIU CONTENTS. 

LECTURE LIV. 

PAGE 

Bilious Colic and Dysentery: Causes, Symptoms, Pathology, Diagnosis, Prog- 
nosis, Treatment 547 

LECTURE LV. 

Peritonitis — Acute and Chronb: Causes, Symptoms, Pathology, Diagnosis, 

Prognosis and Treatment. . 572 

LECTURE LYI. 
Hepatitis: Varieties, Symptoms, Pathology, Diagnosis, Prognosis, Treatment. 589 

LECTURE LVII. 

Spleenitis, Acute Nephritis: Causes, Symptoms, Pathology, Diagnosis, Prog- 
nosis and Treatment 603 

LECTURE LVIIT. 

•Chronic Nephritis: Causes. Symptoms, Pathology, Diagnosis, Prognosis and 

Treatment , 619 

LECTURE LIX. 

Suppurative Nephritis: Causes, Symptoms, Pathology, Diagnosis, Prognosis, 

Treatment .630 

LECTURE LX. 
Tluxes: Diaphoresis — Causes, Pathology and Treatment. . ... . 638 

LECTURE LXI. 

Serous Diarrhoea, Cholera Morbus and Epidemic Cholera: General History, 

Etiology. 644 

LECTURE LXII. 
Serous Diarrhoea and Cholera Morbus : Pathology and Treatment. . . 654 

LECTURE LXIII. 
Epidemic Cholera: History, Causes, Symptoms, Anatomical Changes. . . 661 

LECTURE LXIV. 
Epidemic Cholera: Treatment and Prophylaxis 671 

LECTURE LXY. 
Dropsies: Varieties, Causes, Prognosis, Treatment. . . . . .678 

LECTURE LXVI. 
Hemorrhages: Varieties, Causes, Consequences, Treatment. V • • • C85 



CONTENTS. IX 



LECTURE LXVII. 

PAGE 

Neurosis: General Physiology and Pathology. ...... 6 l J4 

LECTURE LXVIIT. 

Apoplexy: Varieties, Causes, Clinical History, Anatomical Changes, Diagnosis. . 700 

LECTURE LXIX. 
Apoplexy: Prognosis and Treatment. 707 

LECTURE LXX. 
Hemiplegia: Symptoms, Pathology 714 

LECTURE LXXI. 

Hemiplegia, Paraplegia, Locomotor Ataxia. Hemiplegia: Diagnosis, Prog- 
nosis, Treatment. Paraplegia, Locomotor Ataxia: Symptoms, Prognosis, 
Treatment. 719 

LECTURE LXXII. 
Epilepsy: Varieties, Causes, Clinical History. 724 

LECTURE LXXIII. 
Epilepsy: Anatomical Changes, Diagnosis, Prognosis, Treatment. . . . 731 

LECTURE LXXIV. 
Chorea: Causes, Clinical History, Pathology, Diagnosis, Prognosis, Treatment. 738 

LECTURE LXXV. 

Catalepsy and Convulsions: Symptoms, Pathology, Diagnosis, Prognosis, Treat- 
ment. 746 

LECTURE LXXVI. 

Hysteria: Varieties, Causes, Symptoms, Pathology, Diagnosis, Piognosis, Treat- 
ment. . . 755 

LECTURE LXXVII. 

Insomnia and Neuralgia: Varieties, Causes, Symptoms, Pathology, Diagnosis, 

Prognosis, Treatment 762 

LECTURE LXXVIII. 
Tetanus: Causes, Symptoms, Pathology, Diagnosis, Prognosis and Treatment. . 770 

LECTURE LXX1X. 

Hydrophobia: Causes, Symptoms, Pathology, Diagnosis, Prognosis, Treat- 
ment 776 



x CONTENTS. 

LECTURE LXXX, 

PAGB 

Sun Stroke: Varieties, Causes, Symptoms, Pathology, Prognosis, Diagnosis, 
Treatment 783 

LECTURE LXXXI. 

Delirium Tremens: Causes, Symptoms, Pathology, Diagnosis, Prognosis, Treat- 
ment 790 

LECTURE LXXXII. 

Mental Derangements: Varieties, Causes, Pathology, Symptoms. . . . 796 

LECTURE LXXXIII. 

Mental Derangements: Clinical History, Diagnosis, Prognosis, Treatment. . 802 

LECTURE LXXXIV. 
Miscellaneous Diseases: Variety, Causes and Tendencies 810 

LECTURE LXXXV. 

Spasmodic Asthma, Laryngismus Stridulus, Aphonia: Causes, Symptoms, Diag- 
nosis, Prognosis, Treatment 815 

LECTURE LXXXVI. 

Cardiac Irritability, Angina Pectoris: Causes, Symptoms, Diagnosis, Prognosis, 
Treatment 822 

LECTURE LXXXVII. 

Exophthalmic Goitre, Fatty Degeneration of Heart, Aneurism: Symptoms, Pathol- 
ogy, Treatment 829 

LECTURE LXXXVIII. 

Functional Derangements of Digestive Organs: Their Nature and Treatment. 835 

LECTURE LXXXIX. 
Parasites: Varieties, Symptoms and Treatment. 843 

LECTURE XC. 

Diabetes: Diabetes Insipidus— Symptoms, Anatomical Changes, Prognosis, 
Treatment. Diabetes Mellitus— Symptoms, Pathology 850 

LECTURE XCI. 

Diabetes Mellitus, continued: Diagnosis, Prognosis, Treatment. Enuresis: 
Treatment 856 

LECTURE XCII. - 

Alcoholic Liquids as Therapeutic Agents. What Indications are They Actually 
Capable of Fulfilling in the Treatment of Disease? What Substitutes may 
be Employed with Advantage to the Patients? . . . . . • 862 



PART I. 

ELEMENTARY CONSIDERATIONS, OR PRINCIPLES 

OF MEDICINE. 



LECTURE I. 

Definitions of Disease— A knowledge of what constitutes health necessary to a clear conception of 
Disease— Analysis of Health— The Fluids— The Solids— Their properties and relations— Elemen- 
tary Properties— Elementary Functions— Tabular Statement. 

GENTLEMEN: In investigating the principles and practice of medi- 
cine, whether in the lecture-room or in the hospital-wards, morbid 
action and disease in its various forms, tendencies and results, will consti- 
tute the primary theme of discussion and observation. 

To determine the exact pathological condition of the patient, is the first 
object of every enlightened practitioner when called to the bed-side of the 
sick. Having done this, he sees clearly, both the tendencies of the case, 
and the indications to be fulfilled by the employment of remedial agents. 
If the practitioner comprehends fully the nature, extent and tendencies of 
the disease before him, and sees distinctly the objects to be accomplished 
by treatment, he will find it comparatively an easy task to select and apply 
the appropriate remedies. Hence, while standing here upon the thresh- 
old of the present course of instruction we are confronted with the ques- 
tion: What is morbid action or disease? Most of the modern writers 
and teachers in this department, simply reply, that disease is a deviation 
from health in some one of the structures or functions of the human 
system. 

This, instead of explaining anything however, simply necessitates an- 
other question, namely: What is health ? And if the answer is made in 
the usual manner, that health is the natural condition of the structures 
and functions of the human body, it simply changes the phraseology with- 
out advancing our knowledge of the subject. If disease is merely a de- 
parture from a healthy or natural condition of some structure or function, 
it is evident that a clear and accurate knowledge of what constitutes the 
proper standard of health, both in regard to structural organization and 
functional action, affords the only basis on which we can appreciate such 
deviations from that standard as constitute morbid action or disease. To 
gain a full and accurate idea of health as a base-line or point of departure 
for studying the elementary forms of disease, it is necessary to subject the 
animal economy to a proximate analysis sufficient to display the several 
elementary structures, their properties, their mutual relations, and their 
special functions. By such analysis we may resolve all the materials of 
the body, first, into fluids and solids. The first consists of the blood and 

(ii) 



12 ELEMENTARY CONSIDERATIONS, 

the various products of secretory action; and the second, of the organized 
living structures and the solid inorganic materials deposited in them. The 
blood is a very complex fluid, containing all the products of digestion and 
assimilation on the one hand, and the primary products of disintegration 
or waste of structures on the other, together with certain elementary forms 
of organization known as red and white corpuscles. Hence its constit- 
uents or proximate elements may be arranged under three heads, viz: 

1st. Such elements as are nutritive, that is, designed to supply the 
waste of tissues, as albumen, white corpuscles, fatty matter, certain salts, 
and oxygen. 

2d. Such as are derived from the disintegration of tissues and are con- 
sequently effete, as fibrin, extractive matter, certain salts, and carbonic 
acid gas. 

3d. Such as possess, at least, a partial organization and vitality, and 
serve their purpose in the blood, as the red corpuscles. 

The secretions of the animal economy may be divided into three class- 
es, viz : 

1st. Such as are wholly effete or excrementitious, and consequently 
cannot be retained without producing a disturbing or injurious influence. 
To this class belong the eliminations from the skin, lungs, kidneys, and 
mucous membrane of the intestines. 

2d. Such as are retained for the accomplishment of some specific pur- 
pose in the system, and are either reabsorbed or disappear by entering 
into new combinations of a harmless character. To this class belong the 
salivary, gastric, and pancreatic secretions, all of which enter into com- 
bination with the elements of food and disappear in the processes of di- 
gestion and assimilation. To the same class also belong the secretions 
from the serous, mucous, and synovial membranes that serve to moisten or 
lubricate their surfaces. 

3d. Such as are partly excrementitious and partly retained to aid hi 
the processes of digestion and assimilation. The bile is the most promi- 
nent sample of this class, the alkaline constituents of which undoubtedly 
enter into combination with the oily ingredients of chyme in the duode- 
num, while its coloring matter and cholesterin are as certainly effete and 
are discharged with the fceces. 

For a detailed statement of the composition, properties, and uses of the 
blood and secretions, I must refer you to the departments of physiology 
and organic chemistry. But those of you, gentlemen, who have confined 
your reading principally to the works of English and American writers on 
physiology, may be surprised to hear me mention the fibrin of the blood in 
the class of wholly effete substances. For, until a very recent period, it was 
almost universally regarded as a product of assimilation, at least partially 
endowed with vitality, and designed to enter largely into the nutrition of 
the tissues. Such was the view taken of this substance by Carpenter, 
Williams, Paget, Dunglison, and many other writers of an earlier date. 

Zimmerman was perhaps the first to seriously call in question the cor- 
rectness of this doctrine, and to suggest that the fibrin of the blood was 
an effete constituent, derived from the disintegration of tissues, and de- 
signed for excretion. It was shown by Nasse and Miiller that there is no 
fibrin in chyme, and but a very small quantity in the chyle of the lac- 
teals, while it is abundant in the lymph of the lymphatics It is univer- 
sally acknowledged to be more abundant in the blood during the progress 
of the active phlegmasia, than in health. It has also been found in excess 
in the blood of persons anemic either from loss of blood, want of food, or 
the suppression of some important secretion, as well as in the advanced 



OR PRINCIPLES OF MEDICINE. 13 

stages of tubercular phthisis. Indeed, a careful and extended series of 
clinical observations, long since, led me to believe that whenever the 
processes of disintegration or waste of tissues continued active, while the 
secretory action of the kidneys was diminished, fibrin accumulated in the 
blood in quantity above the natural proportion. As these conditions, 
whether arising from the influence of an active local inflammation, or from 
anemic and debilitated states of the system are almost always associated 
with loss of appetite and impaired or suspended digestion, it is extremely 
difficult to account for the increase of fibrin on the supposition that it is a 
product of digestion and assimilation. But its accumulation under such 
circumstances is in perfect harmony with the theory that it is one of the 
primary products of disintegration. While investigating this subject in 
the autumn of 1850, it occurred to me that a careful comparison of the rel- 
ative proportion of fibrin in the blood of the renal vein returning from an ac- 
tive excretory organ, with that in the iliac vein returning from non-secre- 
ting structures, together with that in the arteries, would go far towards 
demonstrating fully the question whether fibrin was a nutritive or effete 
constituent of the blood. The only attempt of this kind, which I could 
then find on record, was made by Simon,* who procured the blood from the 
renal vein, the hepatic vein, and the aorta of a horse, and subjected each 
specimen to an analysis with special reference to the relative proportions 
of water, albumen and fibrin. These results showed of fibrin in the blood 
from the aorta, 8.2 parts in the 1,000; in that from the hepatic vein, 2.5 
parts in the 1,000; in that from the renal vein, none. These results ob- 
tained by Simon, though strongly corroborating the view that fibrin is 
effete, were diminished in value by the fact that the horse from which the 
blood had been obtained was not healthy and well fed, and the quantity 
of blood obtained from the renal vein (only 50 grains ), was insufficient to 
determine accurately the proportion of fibrin. 

To obviate these objections, and at the same time to add another im- 
portant element to the comparison, I selected a good sized, healthy dog, and 
while stunned by a blow on the head quickly opened the abdomen, passed 
a ligature around the renal vein near its junction with the ascending vena 
cava, and from a puncture in it received into a cupping glass 590 grains 
of blood for analysis. 

A ligature was next passed around the iliac vein, and through a suit- 
able puncture 771 grains of blood flowed readily into another cup. A 
third specimen, amounting to 425 grains, was then obtained from the left 
ventricle of the heart. On subjecting these several specimens of blood to 
a careful qualitative analysis, that from the renal vein was found to con- 
tain twenty per cent, less fibrin than that from the left ventricle, while 
that from the iliac vein contained about ten per cent more.j- Robin, 
Bernard, and others have since shown that the blood from the hepatic 
vein also contains less fibrin than that from the jugular vein or from the 
vena cava The fact thus clearly established, that the quantity of fibrin 
diminishes while the blood is passing through the principal excretory or- 

* See Simons' Chemistry of Man, page 139. 

fSee an experimental inquiry concerning some points in the vital processes of assimilation and 
nutrition, published in the North Western Medical and Surgical Journal, p. 169, vol. 4, 1851. The 
analytical results referred to are as follows: 

Blood from Blood from 

Arterial Blood. Iliac Vein. Renal Vein. 

Water 812.2 

Red corpuscles 82.5 

Fibrin 2.2 

Albumen (fat and extract mat- 
ter not separated 98.1 

Salts 5.9 



8119 , 


, 803.4. 


92 7 


92.2. 


2 5 


1.7. 


89 5 , 


98.5. 


3.9 


4.2. 



14 ELEMENTARY CONSIDERATIONS, 

gans, and increases while passing through muscular and non-secreting 
structures, shows conclusively its effete character, and leaves no reason for 
hesitation in classing it as one of the primary products of disintegration, 
or waste of the tissues. This brief review, and classification of the more 
important natural constituents of the fluids of the body, will be sufficient 
for our present purpose, with the additional remark that when all these 
constituents exist in their natural relative proportions and natural quali- 
ties, without the intermixture of deleterious foreign ingredients, the 
fluids present the proper standard of health. 

The solids, or organized structures, that enter into the formation of the 
living animal body, may, for our present purpose, be resolved into five 
proximately elementary forms of organization, namely : the nervous, the 
muscular, the capillary vascular, the secretory, and the fibrous. I do not 
mean that these are the elementary or primary forms of organic matter, 
but the elementary forms of organized structure, each of which is capable 
of performing a distinct function. Of these five elementary struct- 
ures, with the addition of certain inorganic materials, all the complex tis- 
sues and organs of the human body are composed. 

Whether these several distinct structures or primary tissues are each 
composed of elementary cells united in a definite manner, as claimed by 
a large majority of the histologists of the present day, or non-cellular or- 
ganic atoms, we leave for our distinguished colleague in the chair of 
histology, to demonstrate to you. For whatever may be the prima- 
ry form of organization, whether a cell, a nucleus, a granule, or an 
atom; a little reflection will make it apparent to each one of you, that the 
same properties or forces would be required to effect their union in such 
definite modes as to form in one case a muscular fibre, in another a nerve 
fibre, in a third a white or yellow elastic fibre, in a fourth a secreting cell, and 
in a fifth a capillary tube. Hence it is not so much the form of the pri- 
mary organic atom that interests us, as it is the properties or forces with 
which it is endowed, and which control its movements, its combinations, 
and its ultimate destiny. An investigation of the former could do but 
little more than gratify a laudable curiosity, while on the correctness of 
our appreciation ot' the latter depends the clearness of our conceptions in 
regard to the essential phenomena of of life and organic changes, both in 
health and disease. 

What, then, are the properties, if any, with which living organized mat- 
ter is endowed ? 

Perhaps no subject in the whole range of medical sciences has been left 
involved in greater obscurity than this. That living organized matter is 
possessed of certain properties which give to its changes and developments 
certain determinate directions, and enable it to resist the action of such 
agencies as control the changes in inorganic or dead matter, has been 
plainly acknowledged from the most ancient records of medical opin- 
ions to the present time. 

The ancients regarded these properties as purely chemical or phj^sic- 
al, as developed in the various modifications of the humoral theories of 
concoction, fermentation, etc. ; or as some superadded essence, spirit, 
or controlling anima as represented in the earlier theories of solid- 
ism, and more fully developed by Stahl and his disciples. It was not 
until Haller had clearly demonstrated the existence of an inherent proper- 
ty in the muscular structure, which he styled "irritability" that we find 
a distinct recognition of a property or force in organized matter neither 
dependent on, nor necessarily connected with, the immaterial spirit or 
soul. He, however, restricted the existence of this property to muscular 



OR PRINCIPLES OF MEDICINE. 15 

fibres alone; and failed to make any clear distinction between the elemen- 
tary property inherent in the living fibre and the function or office per- 
formed by such fibre. The latter error has prevailed to a greater or less 
extent in the writings and teachings of all the advocates of solidism or 
vitalism even to the present time. Thus Dr. Williams, in his Principles 
of Medicine, speaks of irritability and tonicity, as elementary properties 
of muscular structures, while he calls sensibility and transmisibility/imc- 
tions of nerve structures. Dr. Marty n Paine, in his Institutes of Medi- 
cine, claims one vital principle, which he considers as synonymous with vi- 
tality or life, and which pervades all living matter. This vital principle he 
endows with six properties, namely, irritability, mobility, vital affinity, 
vivification, sensibility, nervous power. Now, gentlemen, tonicity as ex- 
plained by Dr, .Williams means simply a certain degree of muscular con- 
traction, and consequently is as purely a function of the muscular structure 
as sensibility is of the nervous. So, the mobility, sensibility and nervous 
power of Dr. Paine, are plainly functions of the muscular and nervous 
tissues; and yet he classes them in the same catgeory with irritability and 
vital affinity, which are really properties common to all tissues. Dr. 
Samuel Jackson, of Philadelphia, in his work on the Principles of Medi- 
cine, exhibits a much more correct appreciation of the distinction between 
elementary properties common to all the tissues, and elementary func- 
tions of particular parts. But since the more complete development of 
the physiology of the nervous tissues, the great majority of medical writ- 
ers have completely confounded all elementary properties with nerve sen- 
sibility, or, as they term it, nerve force; and have consequently recognized 
no capacity for receiving impressions or modifications of actions in the 
several elementary structures, except through the medium of nerve mat- 
ter. Hence you will find most of the writers on pathology and practical 
medicine, endeavoring to trace the primary actions of all morbific causes, 
to an impression, either directly on the constituents of the blood or upon 
some part of the nervous system. This error has not only caused many 
important questions in pathology to remain involved in obscurity, but has 
also equally retarded the progress of our knowledge concerning the mo- 
dus operandi of our remedial agents. That there are certain properties 
inherent in all organized matter, so long as it retains the capacity to ex- 
hibit the phenomena of life, is evident from facts familiar to all of you. 
Take, for example, the simplest form of organization — the germinal cell 
of the ovum or the chit or germinal part of the vegetable seed. Each is 
destitute of all trace of either capillary vessels or nerves, yet each is sus- 
ceptible to the impressions of certain exterior agents or influences; and 
whenever these are applied, a series of regular and determinate changes 
commence, constituting the active phenomena of life. 

It requires but a moment of careful, logical thought to recognize here 
the existence of two inherent elementary properties : one imparts to the 
cell or germ the capacity to receive impressions, and hence, I have called 
it, susceptibility. The other causes the atomic changes which result from 
the impressions received, to follow certain laws, both in the addition of 
new atoms and the liberation of old ones ; and I have therefore called it 
vital affinity. Susceptibility and vital affinity are the elementary prop- 
erties of all organized living matter. It is the possession of these prop- 
erties that gives to the protoplasm of Mr. Huxley and the bioplasm of Mr. 
Beale, all their peculiarities and capabilities of development. It would 
be a waste of your time to speculate as to the nature of these properties. 
They constitute the peculiar and elementary forces of the organic world, 
and can be recognized and studied only by their effects, in the same 



13 ELEMENTARY CONSIDERATIONS, 

manner that we recognize and study the imponderable or elementary 
forces of the inorganic world, as heat, electricity, attraction, etc. You 
suspend two inorganic substances in the same cup of water, and if they 
unite, forming a new material, you say the union was the result of a 
property or force in the combining bodies, which you call chemical affin- 
ity. You do not see this property or force, yet for that reason you do not 
doubt its existence. So if we place the germinal cell of the animal or 
vegetable in certain relations, we find it uniting with other atoms of mat- 
ter, and forming — not a new and homogenious compound, as in the dis- 
play of chemical affinity — but a complex and progressive series of addi- 
tions constituting growth or development, and I call the property or 
force in the germinal cell by which these changes are effected, vital 
affinity. These properties — susceptibility and vital affinity — are elemen- 
tary, and inherent in all organized living atoms of matter, however dor- 
mant such atoms may appear to be. Deprive the germ, whether animal 
or vegetable, of these properties, and it immediately becomes subject to 
the same laws and forces that govern inorganic matter. Expose it to 
warmth and moisture ever so sedulously, and instead of the phenomena 
of life, you have only those of disintegration and decay. To recognize 
the existence of these properties and learn how far they are capable of 
being acted upon and modified by exterior forces and influences, is a very 
important part of the study of physiology and pathology. 

In another part of this lecture it was stated to you that all the organ- 
ized parts of the body can be resolved anatomically into five primary 
structures, namely — nervous, muscular, secretory, vascular, and fibrous. 
The elementary properties, susceptibility and vital affinity, are general, 
and belong equally to all the primary structures. And each of these 
structures thus endowed with the elementary properties, is capable of per- 
forming certain acts or serving certain purposes which constitute the spe- 
cial or primary function of such structure. For example, the nervous 
tissue receives and transmits impressions ; the muscular contracts ; the 
secretory elaborates some special fluid called a secretion ; the capillary 
vascular allows the active passage of fluids, and at the same time perme- 
ation and imbibition, exosmose and endosmose, through its walls ; while 
the fibrous tissue simply affords both a support and a bond of union to 
all the other structures. Hence, we may conveniently designate the pri- 
mary functions as follows : 

Nerve structure j "Skity. 

Muscular structure, ....... Contractility. 

Secretory structure, Secretion. 

Capillary vascular structure, .... Movement of fluids. 
Fibrous structure, Elasticity. 

You have already learned in your course on histology that these sev- 
eral primary structures are formed by the union of cells or organic atoms, 
varying from each other both in their form and the manner of their union; 
such variations constituting the apparent differences between one struc- 
ture and another. You have also learned that the same primary structure 
is not homogenious throughout, but presents diversities in the union of its 
primary atoms or cells. The nerve structure, for instance, presents in 
some places its cells aggregated in masses, as in the ganglia of the sym- 
pathetic and spinal nerves, and in the gray matter of the brain and spinal 
cord, and in other parts they are united in linear form, constituting fibres, 
as in the white portion of the brain, spinal cord and nerves. The former 



OR PRINCIPLES OF MEDICINE. 



17 



indicates the function of sensibility and the active generation of the 
nerve force, while the latter appears simply conducting or transmitting in 
its function. Still more strikingly you see the elementary cells of the 
secretory structure, in one place united in such form as to present a sin- 
gle follicle ; in another a tubule, and in another a lobule of a conglom- 
erate gland. And every variation thus in the minute anatomy or histol- 
ogy of any primary structure, indicates a corresponding modification of 
its function. 

To make the foregoing brief analysis more easily understood, we will 
place it in tabular form on the blackboard before you, as follows : 



COMPOSITION 

OF 
THE BODY. 



Fluids. 



f Albumen. 
Nutritive Constituents. \ %**£&?"■ 
I Salts and Oxygen. 

Blood ^ Formative -j Red Corpuscles. 



Excrementitious 



( Fibrin. 

■j Extractive Matter. 

( Salts and Carbonic Acid. 



Used in the Sys- 
tem. 



Saliva. 

Gastric Juice. 
Pancreatic Fluid, etc. 



Secretions. «{ Partly Retained and Excretory - Bile 

C Cutaneous. 
Excrementitious. ■< Pulmonary. 

/ Renal Secretions, &c. 



q nTmo j Resolvable into Five 
b0LIDS * ' 1 Elementary Struc- 



tures. 



r Nervous. 
Muscular. 
Secretory. 
Capillary Vascular. 
Fibrous. 



Elementary Properties and Functions. 

Properties Common to all Organized Living Matter, \ Susceptibility. 
Therefore Elementary . j Vital Affinity. 



Functions Peculiar to Each 

Structure ; 

Therefore Elementary. 



Sensibility 



Nervous Structure. 



Transrnissibility . ( 

Contractility . . \ Muscular. 

Secretion . . . . \ Secretory. 

Movement of Fluids with ) ~ •« \r nnn ■. 
Exudation and Imbibition Capillary Vascular. 



Elasticity . . 



Fibrous. 



In these two tables you are enabled to see at a glance the primary 
composition, properties and functions of the human body. Reflect upon 

2 



18 ELEMENTARY CONSIDERATIONS, 

them, gentlemen, until each of them is clearly appreciated and fully im- 
pressed upon the mind. 

That which will be most difficult for you to appreciate, and trace accu- 
rately in the study of the more complex structures and functions, is the 
difference between the susceptibility as an elementary property- of all liv- 
ing matter and the elementary function peculiar to nerve matter called 
sensibility. If you remember, however, that the first is a passive quality 
or endowment of each and every atom of living matter, imparting the ca- 
pacity to be acted upon by various agents; while the other involves both 
a special structure and a positive local action, you will not be likely to 
confound them with each other. For instance, a muscular fibre made up 
of a peculiar arrangement of atoms or cells and endowed with the prop- 
erty susceptibility, receiving a current of electricity or a nervous impres- 
sion from either a mental or organic nervous centre, performs its pe- 
culiar function by contracting. But if the muscular fibre be first washed 
with a solution of carbonic or hydrocyanic acid by which its susceptibility 
is destroyed, neither electricity nor nervous force will elicit from it the slight- 
est action. The same is illustrated in the processes of secretion, nutrition, 
etc. If the secreting cell is endowed with its - proper susceptibility and 
the blood containing the proper elements is brought in contact with it, an 
active process takes place by which a new fluid is evolved, called a secre- 
tion. The vaso-motor nervous force, by altering the action of the blood- 
vessels and consequently the supply of blood, may modify secretion, but 
does not either produce or suppress it. The exhibition of nervous force 
requires a special apparatus or anatomical structure; while the results of 
susceptibility and vital affinity are seen wherever there is a cell or atom of 
iivino; matter whether animal or vegetable. 

It is the possession of these properties that distinguishes living organic 
matter from dead matter. If you ask, from whence are they derived, I 
answer that so far as reliable observation has yet reached, they are derived 
with the germ from the parent, and in no other way. They are neither 
material agents, nor active organic forces, but simply properties of living 
matter, by which such matter becomes susceptible to the influence of ex- 
ternal agents, on the one hand; and specific direction is given to whatever 
molecular changes take place, on the other. 

If you now fix your attention upon the tabular, statements on the black- 
board, and get clearly delineated in the mind the human body, composed 
of the several elementary structures, each with its own peculiar arrange- 
ment of organic atoms, possessed of its elementary properties, and per- 
vaded by the fluids in their normal proportion and composition, you will 
have an adequate idea of health as applied to the animal organization in a 
passive condition. But to make the picture complete and capable of prac- 
tical application another element must be considered, namely, the action of 
exterior agents. Organized bodies, like all other ponderable matter, are 
inert or passive until acted upon or brought in contact with certain exterior 
agents or influences. The vegetable germ may be complete in its organi- 
zation and its germinal cell endowed with the necessary properties, but 
until it receives the exterior impression of heat and moisture, it will ex- 
hibit no sign of activity or life. So the human body may have every 
structure complete in the arrangement of its atoms; the fluids may be 
perfect in their quantity and quality, and the whole may be possessed of 
the required susceptibility and vital affinity, yet no action or sign of life 
will be seen until the application of an external force or influence, such 
as atmospheric air containing oxygen, heat and electricity. Three things, 
then, are essential to constitute what we term health; namely, an exact 



OR PRINCIPLES OF MEDICINE. 19 

formation and arrangement of atoms or cells constituting the several 
structures of the human body, the proper quantity and composition of the 
fluids, and the presence in due quantity and quality of the external agents 
just alluded to. When all these exist in their normal relations to each 
other, the phenomena of life are manifested in a strictly normal or healthy 
manner. 

By these remarks, gentlemen, you will perceive that to gain the first 
or preliminary step necessary to the philosophical study of disease, you 
need to be perfectly familiar with the departments of anatomy, physiology, 
chemistry and physics, in their most complete development. 



LECTURE II. 



Analysis of Disease— Tts Elementary Forms— Changes in the Blood- Changes in the Organized 
Tissues— Functional and Structural Disease— Tabular Statement— Why all Attempts to Build 
up Systems or Theories of Medicine Founded on Some Supposed Universal Principle of Morbid 
Action, have Failed. 

GENTLEMEN: Having in the preceding lecture subjected the human 
body to an analytical examination, and pointed out the elementary 
items which, aggregated, constitute what we term health, you are pre- 
pared, by following out the analysis, to appreciate the elementary forms 
and conditions of morbid action constituting disease. If disease is simply 
a deviation from the natural or healthy condition of some part of the 
human system, we inquire first as to the directions in which such deviations 
are possible. Reflection and clinical observation alike show us that devia- 
tions from the normal standard may take place in three directions, namely: 
increase, diminution, and perversion. If we give our attention, first, to 
the fluids of the body, we find the blood capable of being increased in 
quantity so as to cause over-fullness of the vascular system, constituting 
what pathologists term plethora. In other cases it is diminished in 
quantity so far below the natural standard as to leave the vascular appar- 
atus without the proper distension, which constitutes anaemia. In still 
another class of cases the blood may be neither increased nor diminished 
in quantity, but its proximate elements may be altered in their relative 
proportion, or in their quality, or by the intermixture of some foreign sub- 
stance, which several conditions may be included under the general term 
perverted. If we turn our attention from the blood as a whole, to its sev- 
eral constituents, we find each capable of undergoing the same deviations 
from the standard of health. Either one or all of the nutritive and form- 
ative constituents may be increased, constituting a hyperaemic or hyper- 
plastic condition; or they may be diminished, constituting spanaemia, or 
poor blood; or their properties may be so altered as to constitute septicae- 
mia, or blood degeneration. The latter, however, is much more frequently 
induced by either excess or alteration of the effete constituents of the 
blood. When some deleterious agent is introduced into the blood, capa- 
ble of altering its properties, the condition is called toxaemia. 

If we pass to an examination of the secretions, we shall find them all ca- 
pable of undergoing the same primary deviations from the normal or 



20 



ANALYSIS OF DISEASE. 



healthy standard. That is, each is capable of being simply increased above 
the normal quantity, or diminished below it, or perverted either by altera- 
tion in the relative proportion of its constituents or by the introduction in- 
to it of some foreign ingredient. The urine, for example, may be exces- 
sive constituting diabetes insipidus; or it may be diminishe*d as in the 
inflammations; or it may contain less or more than the normal quantity of 
urea, uric acid, and salts, or it may contain new ingredients as albumen, 
sugar, &c. The same is true of the cutaneous, gastric, salivary, and all 
other secretions. Perhaps it will aid you if we place on the blackboard the 
following tabular summary: 



FLUIDS 

OF THE 

HUMAN 

BODY. 



Nutritive 
Constituents. 



Albumen 

White Corpuscles. 

Fatty Matter 

Salts 

_ Oxygen 



Primary 

Morbid 

Conditions. 



C Increased. 
■< Diminished. 
I Perverted. 



Blood i 



Formative 
Constituents, 



■I Red Corpuscles. j-Do 
I J 



["Fibrin 1 

Effete J Extractive matter. I -p, 

Constituents. 1 Salts f U0 

^ Carbonic Acid J 



Secretions 

used in the-! 

System. 



Saliva 1 

Gastric Juice . . . 
Pancreatic Juice. 

Mucus _ r Do 

Synovial, 

and Serous 
Fluids 



Increased . 

Diminished. 

Perverted. 

f Increased. 
■I Diminished. 
I Perverted. 



"1 Increased. 
Y Diminished. 
J Perverted. 



Secretions f Cutaneous . . . ] 
Secretion, i wholly i P * 1 ^ n a r U Do 
Excretory.j §£*£•*/ 



Increased. 

Diminished. 

Perverted. 



Mixed ,' Hepatic and 
Secretions. 1 Intestinal. 



*| Increased. 

Do > Diminished. 

J Perverted. 

In making this tabular sketch, I have not included in each division 
all the particular secretions that belong to it, but the most important, which 
will be sufficient to clearly indicate the morbid deviations, we are endeav- 
oring to point out, and their applicability to each and all the fluids of the 
human body. 

If we turn our attention to the solids or organized structures of the 
body, we shall find them capable of presenting similar deviations from the 
healthy condition, either in their properties, their functions or their struc- 
ture. 

For instance, the elementary properties common to all the tissues may 
be increased or diminished or perverted. In speaking of these properties, 
susceptibility and vital affinity, as capable of increase and diminution, I do 
not wish to convey the idea that they are separate substances, to be increased 
or diminished in quantity or bulk, as we would the quantity of air or water or 
any other material substance. I simply mean that the structures endowed 
with these properties are capable ol being so influenced as to manifest them 



ANALYSIS OF DISEASE. 21 

ill a greater or less degree of activity, or in some unusual direction. We see 
one person who either from hereditary or acquired influence, has become 
so easily affected by ordinary external impressions, that the slightest 
atmospheric changes are liable to produce exaggerated effects. His sus- 
ceptibility is too great. Another presents directly the opposite. Neither 
atmospheric changes nor other excitants produce the ordinary influence, 
and we say his susceptibility is impaired. 

Again, we find one person with rich blood, active atomic or molecular 
changes, and not only active nutrition, secretion and calorification, but the 
slightest exudation into any of the structures or upon the membranous sur- 
faces, is rapidly organized into new tissue, causing indurations, adhesions 
or increased growths. In such the play of vital affinity is manifestly 
increased above the normal standard. In surgical phrase, he has a hyper- 
plastic diathesis. In another person we may find the reverse of all this. 
The ordinary, organic changes are slow ; nutrition, secretion, and calorifi- 
cation are but feebly maintained ; and if exuditions take place, instead of 
rapid organization and acquisition of vitality, they degenerate, causirg 
softening of tissue, diffuse suppuration, and diminished nutrition or growth. 
It is plain that in such we have impaired or feeble vital affinity, and pathol- 
ogists style it an aplastic diathesis. In still another case or class of cases, 
we find the molecular changes not merely increased or diminished, but so 
altered that atoms are attracted to and retained in tissues where they do 
not naturally belong, causing metamorphosis of tissue as when cartilage 
becomes bone, muscular fibre fatty tissue, &c. Or still further, causing 
the primary atoms or cells to be formed erroneously and to accumulate in 
the form of tumors or morbid growths. These are evidently all results of 
a perverted vital affinity. The several alterations in the elementary prop- 
erties, constituting primary morbid conditions, may take place in all the 
tissues and organs at once, constituting a general morbid condition of the 
w T hole system ; or they may occur in only one tissue or organ constituting 
local predispositions and derangements. If the deviation is general and 
derived from hereditary influences, or acquired from causes acting feebly 
but continuously through a long period of time, the individual will present 
some one of those conditions called diatheses or predispositions, such as 
the plastic and aplastic, scrofulous, cancerous, rheumatic, gouty, &c. But 
if the causes act with more suddenness and intensity, producing more 
abrupt and exaggerated disturbance of the properties, there will result 
some one of the more acute forms of disease, such as fever, inflammation, 
or active irritation. 

Primary Alterations of Function. — The fact that the natural or 
healthy performance of any function depends on the coincidence of three 
things, namely: the proper arrangement of atoms constituting normal struc- 
ture, the endowment of the structure with the properties in their normal de- 
gree, and the presence of the proper stimulus in the normal proportion, it 
follows that the failure or disturbance of either of these conditions must 
be followed by corresponding failure or disturbance of function. And as I 
have just stated, that either or both of the elementary properties are capa- 
ble of being increased, diminished or perverted, so we may have the same 
primary deviation from the natural condition in any one or all of the 
functions in the human body. The function of the secreting structure 
is to separate from the blood certain materials in a fluid form, called a 
secretion. The secreting cells of the kidneys, for example, elaborate 
urine. And few things are more familiar than the fact that the quantity 
secreted in a given time maybe excessive or deficient, or it may be al- 
tered in quality — perverted, either by the omission of one or more of its 



22 



ANALYSIS OF DISEASE. 



natural constituents, or by the intermixture with it of foreign sub- 
stances, as albumen, sugar, coloring matter of bile, etc. The special 
functions of the nervous structure are sensibility and transmissibility. 
And there are but few morbid phenomena more familiar to the physician 
than increased sensibility, technically called hyperesthesia, and dimin- 
ished sensibility, called anaesthesia, and many cases are presented in 
which the sensibility is altered in such a way as to convey an impression 
of a morbid character, such as heat and cold when there is no real change 
of temperature; or a sapid substance tastes bitter, or a bitter one sweet. 
These constitute per/erted sensibility. These familiar illustrations are 
sufficient to show you that each function of the human system is capable 
of being altered from the standard of health in three directions, namely: 
increased above, diminished below, and perverted. Hence, we may ex- 
press the primary morbid conditions of the organized tissues in tabular 
form as follows: 



ELEMENTARY 

FORMS 
OF DISEASE 



f Elementary 
Properties. 



Susceptibility 



Vital Affinity. 



j Increased. 

( Diminished. 



•1 



f Increased. 
1 Diminished. 
Perverted. 



Elementary 
„ Functions. 



Sensibility agdfg-^d. 

Transmisslblllt y 1 Perverted. 



Contractility. 



f Increased. 
-I Diminished. 
L Perverted. 

f Increased. 
< Diminished, 
t Perverted. 



Ca £ m ^3 S ; J Increased. 
|te ^ | Diminished. 



■{ Secretion. 



Elasticity. 



Increased. 
Diminished. 



Primary Alterations in Structure. — The same analytical mode of in- 
vestigation applied to the study of structural changes, will show them 
capable of being resolved into three classes, namely: one in which vital 
affinity being active and the supply of nutritive material abundant, the 
addition of new atoms, constituting nutrition, exceeds that of disin- 
tegration, and hence there is an increased growth, a hypertrophy. 
Another, in which either the vital affinity is diminished, or the supply of 
nutritive material is deficient, and in consequence the nutrition is less 
than natural, constituting atrophy. While the third class embraces those 
cases in which the vital affinity is perverted or altered in such a way as 
to cause the attraction and accumulation of atoms not belonging to the 
particular structure affected. This necessarily results either in the trans- 
formation of the structure, as in the conversion of muscular fibre into fatty 
matter, cartilage into bone, etc., or in some one of the morbid growths, or 
tumors. These latter may be osseous, fibrous, fibro-cartilaginous, cartil- 
aginous, fatty, or malignant. 



ANALYSIS OF DISEASE. 23 

From this rapid review, you perceive clearly that we may have regular 
deviations from the standard of health, either in the direction of excess, 
diminution, or perversion, in all the elements that go to make up the ani- 
mal economy: in the blood, as a whole, and in the several constituents 
separately; in the secretions; in the properties common to all the tissues; 
and in the functions peculiar to each structure. To complete the review, 
we may apply the same rule to those natural excitors that act habitually 
upon the living- organization from without, they being capable of acting 
in excess, or deficiency, or with properties so altered as to make impress- 
ions different from simple excess or its opposite, and hence termed pervert- 
ed. And here, gentlemen, at this early period in your course, you can readily 
see why every attempt to build up a system of medicine, founded on the 
idea that all disease is a unit, or traceable to some one theory of morbid 
action, has failed in the past, and will continue to fail in the future. It 
matters not whether we take the theory of Brown, which refers all disease 
primarily to either direct or indirect debility; that of Rush, Broussais, and 
Paine, which traces all morbid action to primary irritation or excitement; 
or that of Hotfman modified by Cullen, which refers all morbid action to 
a primary morbid impression on the nervous system, they all fail to recog- 
nize the fact that, disease being a simple deviation from health, must 
present as many different aspects as there are directions in which devia- 
tions can take place. Almost all theories and systems contain some truth. 
Their authors and supporters seeing clearly, perhaps, a single mode of 
morbid action, and looking at this from one standpoint, they endeavor to 
make all the facts of science and the observations of clinical experience 
conform to the one central idea or theory. With them the one clearly 
perceived mode of morbid action is applied to all diseases, either directly 
or indirectly, and hence in their minds it assumes the place of the fabled 
iron bedstead, to which all else must be made to fit. 

Equally futile and transitory have been all the so-called systems of 
therapeutics, founded as they usually have been, upon some preconceived 
theory of disease. Thus the direct and indirect debility of Brown neces- 
sitated the predominant therapeutic law of stimulation so generally adopt- 
ed by his followers; the irritation of the school of Rush, as certainly gave 
rise to the therapeutic law of depletion, while the restriction of the irrita- 
tion primarily to the nervous system, by Hoffman and Cullen, only added 
to the general law of depletion, the use of anodynes and antispasmodics. 
The analytical review I here give you concerning the elementary forms 
of disease, or primary modes of morbid action, will enable you to see dis- 
tinctly just how far any one or all of the special theories of disease and ac- 
companying laws of cure are true, and where they deviate into error. By that 
review it was made obvious that both the properties of the living tissues, the 
functions of particular organs, and the molecular or atomic, changes were 
capable of being so far increased above the normal standard as to constitute 
disease of excitement, and therefore requiring an application of the thera- 
peutic law of depletion or sedation. It was made equally obvious that 
these same properties, functions and molecular changes, might be so far di- 
minished as to constitute disease of debility, requiring the application of a 
law of stimulation, or active support. 

And, again, it was seen that the properties of the blood and tissues were 
capable of such alteration as would cause perverted actions, both in the 
molecular changes in the tissues and the functions of particular organs, 
thereby requiring neither simple sedation or stimulation, but alterant, 
antidotes, and eliminants. You thus see that all these theories are correct 
when the application of each is restricted to a single mode of morbid action ; 



24 ANALYSIS OF DISEASE. 

but they become erroneous and highly mischievous the moment the attempt 
is made to apply any one of them to all morbid action. 

The foregoing observations apply equally well to all the various pathys 
and isms that have from time to time sprung up like mushrooms from the 
fertile soil of medical science. Whether you take the bluntly expressed 
maxims of Samuel Thompson, the founder of Thompsonianism and its 
modification known as modern Eclecticism, that " heat is life and cold is 
death," or the more fanciful dogmas of Hahnemann, that " like cures 
like," and the "smaller the dose the greater the therapeutic power," 
they are equally vain attempts to make the varied and often opposite phe- 
nomena of disease subservient to a single partial law. 

By these observations, I wish to impress strongly upon your minds the 
important fact, that the only true basis or starting point for a rational 
study of disease, is afforded by a thorough knowledge of the anatomy and 
physiology of the human body. Once possessed of a full knowledge of 
the composition, properties and functions of the human system, we are 
prepared to appreciate each deviation, in any direction, from the natural 
condition so far as to constitute disease. With such a preparation, you 
are ready to receive, arrange, and apply the facts and observations of 
clinical experience. 

Instead of espousing some theoretical dogma and vainly striving to 
adjust all the facts of science and observation to it, or bewildering your- 
selves with cumbersome systems of nosology, you carefully study the 
causes and phenomena of disease from the standpoint of health, with a 
view to remove or mitigate the first, and to modify the second in the direc- 
tion towards its 'primary point of departure, in other words towards the 
re-establishment of health. That is, if you find the phenomena or symp- 
toms of disease indicating increased activity or irritation, you strive to 
reduce or subdue the excess of activity ; if indicating depression or 
impairment of activity and excitement, you endeavor to prop up or sus- 
tain ; if indicating neither simple excitement nor depression, but perver- 
sion of action, you call to the aid of your patient such alteratives as 
are best adapted to correct the particular perversion ; and if by continu- 
ance of morbid actions, obstructions or exudations have occurred, either 
in the blood or the tissues, you call into requisition such eliminants, 
alteratives, and tonics as will be most efficient in promoting their removal. 

By such a course you become philosophical practitioners of the healing 
art, true handmaids of nature, ever studying the nature and tendencies of 
her embarrassments, and ever striving to aid in correcting them. 



GENERAL PROCESSES AND COMPLEX FUNCTIONS. 25 



LECTURE III. 

General Processes and Complex Functions— Their Relations to Each Other in Health and 
Disease— What Constitutes Nature— The Efforts of Nature— The "Vis Medicatrix Naturae " 

TN the two preceding lectures I have endeavored to present to you an an- 
alytical view of the elementary structures, properties, and functions of 
the human system in their natural relations, constituting health; and the 
various deviations from that natural relation constituting the primary 
forms of morbid action or disease. Your attention is now invited to a con- 
sideration of certain general processes and complex functions, which result 
from the anatomical and functional union of the various elementary struct- 
ures to which I have alluded. These processes differ from functions, inas- 
much as they are not the result of the action of any one or more of the 
structures, but are constantly going on in all the structures at once. They 
may be termed nutrition, disintegration, and calorification. By the first is 
meant the direct addition of new atoms to the organized structures; by 
the second, the removal of the old atoms as they become useless or super- 
fluous; and by the third, the evolution of heat to maintain the temperature 
of the body. These complex functions are performed by four groups of 
organs, which may be designated the digestive, the excretory, the repro- 
ductive and the mental. The first embraces the alimentary canal and its 
appendages, by which the new material is received, digested, and assimi- 
lated, or prepared for use in the process of nutrition. The second em- 
braces all those organs and structures engaged in the work of receiving 
th3 products of disintegration and removing them from the system, of 
which the skin, kidneys and lungs are the chief. The third, consists of 
the male and female organs of generation. And the fourth is made up of 
the cerebro-spinal nervous apparatus, including the special senses and the 
muscles of voluntary motion. 

In regard to the general processes, it may be remarked that the two first 
named are directly antagonistic, or the reverse of each other. Nutrition, 
which consists in the addition of the new material, derived from the di- 
gestive and assimilative organs, directly to the respective tissues for which 
it has been fitted, is undoubtedly performed in obedience to the attraction 
or affinity of each tissue for the appropriate atoms or cells ; these latter 
passing through the walls of the capillaries by a process which has been lik- 
ened to that of exosmose. The escape of the nutritive material from the 
blood in the capillary vessels and its lodgment in the several tissues, dif- 
fers, however, from the simple physical process termed exosmose, inasmuch 
as only such atoms escape from the vessels into each tissue as are prepared 
to become a part of it, although they are all in one mass in the blood. 

This fact alone, shows that there is in the living structures of the body 
some inherent power of selection, which I have thought best to term affinity, 
or vital affinity. 

As the capillary vessels have no open ends or visible termini, but are 
continuous tubes between the arterioles and veinous radicles, it is not 
easy to explain how the nutritive matter passes from the blood in the ves- 
sels, into the adjacent structures. But it is highly probable that the walls 
of the capillary vessels have pores, through which the primary atoms of 
matter may pass, either from within or without. 



2G GENERAL PROCESSES AND COMPLEX FUNCTIONS. 

You thus see the admirable adaptation of the true capillaries, both as 
connecting links between the arterial and veinous systems of vessels, and 
as the medium through which matter is conveyed to and from all the other 
structures of the body in the processes of nutrition and disintegration. 
"When the matter furnished through the digestive organs is perfect in its 
assimilation, the vascular system unobstructed, and the vital affinity of the 
tissues natural, the process of nutrition goes on healthily and the integrity 
of each part is maintained. During the period of development or growth, 
the process of nutrition predominates over that of disintegration and 
excretion. After maturity and through the active period of adult life, 
these two processes should balance each other. But after passing the last 
named period, disintegration begins to gain supremacy over the nutrition 
and generally holds it in increasing ratio until death by old age. 

The conditions essential to healthy nutrition, are the presence of a suffi- 
cient quantity and variety of perfectly assimilated material, in arterial - 
ized or oxygenated blood passing with a certain rate of motion through 
the capillaries ; and the existence in the structure, of the natural proper- 
ties, susceptibility and vital affinity. If the quantity or variety of food be 
insufficient, or if the digestive apparatus be incapable of perfecting its 
assimilation, nutrition will be retarded, causing loss of flesh or atrophy of 
tissue ; and if this is carried beyond a given point it will constitute dis- 
ease. But if the quantity and quality of food and its assimilation, are 
both natural and complete, yet if the properties of the tissues are altered 
from the natural standard, nutrition will be altered in the same direction. 
If these properties are impaired the attraction of new atoms will be dimin- 
ished, causing either atrophy or softening of structure, or both, as you will 
bye-and-bye see in the low forms of fever. If the properties are increased 
they will cause too rapid an addition of new material, and unless the d's- 
integration be hastened correspondingly, an increased growth or hypertro- 
phy will be the res-ult. If the properties of the tissues are neither 
depressed or exalted, but by the presence of some disturbing agent, are 
perverted, it will result in the attraction and lodgment of atoms in tissues 
where such atoms do not naturally belong, thereby causing the formation 
of aplastic, caco-plastic, or plastic deposits, constituting either transforma- 
tion of structures, deposits, or morbid growths, as explained in the preceding 
lecture. 

The process of disintegration consists essentially in the displacement of 
such atoms as have become useless or superfluous in the several structures, 
and their return through the capillary walls into the mass of the bloo-l, 
constituting what I have already pointed out to you as the effete constitu- 
ents of that fluid. 

The conditions essential for the healthy performance of this process, ap- 
pear to be the presence of the proper proportion of oxygen in the b "ood 
of the systemic capillaries; the normal rate of motion of the blood through 
these vessels; and the natural condition of the elementary properties. The 
presence of a due proportion of oxygen is probably as essential to healthy 
disintegration, as is the proper supply of perfectly assimilated material for 
the process of nutrition. The effete matter resulting from the waste of 
tissues and returned into the blood, is separated therefrom and cast out of 
the sytem through the agency of several important organs, each separating 
a particular class of ingredients, and thereby holding an intimate and im- 
portant relation to each other. The principal organs engaged in this work 
are the skin, lungs, liver, and kidneys. Their relation to the process of 
disintegration, is as intimate and important as is that of the digestive or- 
gans to nutrition. The functions of the skin and kidneys are wholly ex. 



GENERAL PROCESSES AND COMPLEX FUNCIIONS. 27 

eretory, their secretions consisting chiefly of the saline and nitrogenous 
products of disintegration. The functions cf the lungs and liver are, in 
one sense, more complex. While the first give exit to a large part of the 
carbonaceous products of disintegration, with aqueous vapor and a small 
amount of animal matter; it also receives the oxygen which is to be sup- 
plied through the blood to the whole system. So, too, the liver not only 
separates from the blood the products of disintegration in the form of 
cholesterin and coloring matter which are effete and disappear through the 
alimentary canal; but also, certain alkaline constituents that are not effete, 
and which are used in aiding the process of digestion. So important 
are the functions performed by these several excretory organs, that no one 
of them can be entirely suppressed, even for a brief period, without en- 
dangering the life of the whole. Yet so carefully has the author of nature 
guarded against such emergencies, that whenever the function of one of 
these organs is diminished, another, by increased activity, may in part, at 
least, supply the deficiency. This close sympathetic relation of one organ 
with another, is most easily seen in the functional relations of the skin and 
kidneys. Probably none of you have failed to notice the fact, that when 
the skin is unusually active, as in the warm dry air of summer, the quantity 
of urine voided in a given time is much less; and when it is diminished by 
the cold and damp atmosphere of spring and autumn, the quantity of urine 
is proportionately increased. 

Now, so long as these organs maintain this active sympathy and mutu- 
ally compensating action, in any individual, he may freely expose himself 
to sudden and extreme atmospheric changes without harm. But let this 
active sympathy fail, and the very first exposure to marked atmospheric 
vicissitudes will be likely to result in the development of the phenomena 
of disease. 

A similar, though less marked, sympathetic relation exists between the 
excretory functions of the lungs and liver. The four important organs or 
structures under consideration, are not merely the principal sewers, if I 
may so speak, through which the products of disintegration and waste are 
conveyed out of the system, but they are equally the active agents for sep- 
arating from the blood, and turning out of the body, all such foreign and 
disturbing material as may have entered it from without, so far as it may 
be capable of separation. 

The idea so long popular, both in and out of the profession, that the 
blood and tissues could be purified from the presence of offending and 
poisonous material, by acting directly on the stomach and bowels by 
emetics and cathartics, is erroneous. 

It is, indeed, an error that in times past, led to great abuses in the use 
of such evacuants in the treatment of disease; and from which the non- 
professional part of the community have not yet been wholly freed. Before 
leaving altogether the subjects of nutrition and disintegration, I must 
guard you against another error, which the student is apt to espouse from 
a perusal of much of our current medical literature. I allude to the doc- 
trine, inculcated by many writers, that to retard the process of disintegra- 
tion by which old atoms are removed from the tissues, is equivalent to the 
addition of an equal amount of new atoms by nutrition. Hence, those 
agents, like alcohol, which by their presence in the blood are capable of sa 
altering the vital affinity of the tissues as to retard disintegration, are 
styled by them indirect food. And we are gravely told that if a laboring 
man, by taking a certain quantity of alcoholic drink, diminishes the gross 
amount of the excretory products of disintegration to the extent of half a 
pound in the twenty-four hours, it is equivalent to the addition of that 



28 GENERAL PROCESSES AND COMPLEX FUNCTIONS. 

amount of new matter through the organs of digestion and the process cf 
nutrition. 

If it is true that a primary atom or cell of organized animal matter, once 
in its place as a part of a living structure, is capable of performing its of- 
fice for an indefinite period, or so long as it can be retained in its position, 
then indeed retarded disintegration is equivalent to additional nutrition. 
And it will only be necessary to find some agent capable of arresting 
the process of disintegration altogether, and we may live on indefinitely 
without further expense for food, or further loss of time in eating it. Un- 
fortunately for this theory, however, there is uo more imperative physio- 
logical law, or one more prominently inscribed on all living animal matter, 
than that active life and molecular changes are inseparable. When the 
germinal matter or bioplasm stored in the dormant germ, once receives the 
impression of its appropriate stimulus, and the active phenomena of life 
have begun, there has commenced coincidently those molecular changes 
constituting nutrition and disintegration. And throughout the whole king- 
dom of animal life, you will find the activity of these changes to bear a 
direct ratio to the activity of the phenomena of life. Hence to retard 
these changes is to retard or diminish the phenomena of life. And the 
agents that are capable of retarding disintegration, instead of being called 
indirect food, should be classed as organic sedatives, and used only as 
medicines where such sedatives are needed. 

To counteract the ordinary waste of tissues by retarding disintegration, 
instead of furnishing new material by nutrition, is much like retaining the 
limbs of a tree after they have become dead and dry. It may indeed serve 
to retain fullness or bulk, but only to embarrass instead of to sustain the 
processes of life. 

And at the bed-side of the sick you cannot be too careful in discrimina- 
ting between those cases of failure in flesh from deficient assimilation and 
nutrition, and those from excess of disintegration. The former are com- 
mon, and the latter rare. 

Beside the general processes of nutrition and disintegration, I named a 
third, which was called colorification, by which is meant the evolution of 
heat sufficient to preserve the natural temperature of the human body. 
All classes, genera, species and varieties of living animals present a tem- 
perature peculiar to themselves, and generally differing more or less from 
the temperature of the medium in which they live. 

This results from the evolution of free heat by the changes in the con- 
dition of matter, constantly taking place in the tissues of living animal 
bodies. It is a well known law in physics that whenever matter passes 
from a rarer to a denser condition, latent heat is set free and becomes 
sensible; and when matter passes from a denser to a rarer state, free heat 
is absorbed, or becomes latent. If you have studied properly the changes 
in matter produced by the reception and assimilation of food, and other 
ingesta, and its appropriation to the several tissues, you readily see that 
the general result of these functions and processes, is to change the mat- 
ter after fairly entering into the system from a rarer to a denser state, 
thereby tending to increase the temperature by increasing the amount of 
free heat. On the other hand, the changes in matter resulting from disin- 
tegration and excretion as a whole, are of the opposite character, and con- 
sequently result in a tendency to diminish the temperature by converting 
free into latent heat. In the natural or healthy condition of the human 
system, these opposing processes and functions bear such a relation to each 
other in regard to the evolution and absorption of heat as to maintain the 
average temperature of the body at 55° C. (78.6° F.) It is neither neces- 



GENERAL PROCESSES AND COMPLEX FUNCTIONS. 29 

sary nor proper, at this time, to refer to the former theories in regard to 
animal temperature. 

For many years after organic and animal chemistry had begun to attract 
attention, the evolution of heat in the system was attributed to the direct 
union of the oxygen and carbon in the lungs, constituting a species of 
combustion. And several ingenious theories were invented for explain- 
ing its diffusion so equally through the whole system, from the seat of 
combustion in the lungs. The discovery of the fact that the oxygen was 
absorbed from the air cells of the lungs and was carried with the arterial 
blood, and that the carbonic acid gas evolved through the lungs, was not 
formed in those organs, but brought in the veinous blood from the systemic 
capillaries, destroyed all the preceding theories. It did not, however, de- 
stroy thei idea of combustion by the union of oxygen with carbonaceous 
matter. It simply transferred the place of the union from the lungs to 
the systemic capillaries, where Prof. Liebig and his co-laborers of the 
chemico-physiological school of investigators, still retain it. And not only 
so, but they divide the food into nitrogenous and carbonaceous, and rep- 
resent the former as designed to nourish the tissues, and the latter to unite 
with oxygen and form carbonic acid gas to be evolved through the lungs, 
and heat to maintain the proper temperature of the body. It is in ac- 
cordance with this theory that you find in nearly all your books the car- 
bonaceous elements of our ingesta, styled respiratory food. More than 
twenty years since, I met with so many facts connected with the diet of 
individuals and communities, and also with the phenomena of diseases, 
which seemed difficult of explanation without denying the correctness of 
the theory under consideration, that I instituted during the years 1849 and 
1850, several series of experiments and observations, designed to deter- 
mine positively the relations of certain articles or constituents of food and 
drink to the evolution of heat in the human system. The details of many 
of these investigations, with the results or inferences to be deduced from 
them, were embodied in a paper read to the American Medical Associa- 
tion, at its annual meeting in Charleston, South Carolina, in May, 1851 ; 
and subsequently published in the North- Western Medical and Surgical 
Journal, then published in this city.* The results of those investigations, 
together with much subsequent observation relating to the same subject, 
satisfied me that there was no direct relation between the kind of food 
taken and the amount of heat evolved ; and consequently no foundation 
for calling carbonaceous matter respiratory food, more than any other 
matter capable of assimilation. On the contrary, a large number of care- 
fully recorded observations of the temperature of a healthy individual, 
first, under an ordinary mixed diet ; second, under a diet exclusively car- 
bonaceous ; and third, under a diet exclusively nitrogenous, showed that 
the temperature of the body uniformly increased during the active pro- 
cesses of digestion and nutrition, and decreased as these declined. The 
lowest temperature was before breakfast in the morning, after the long 
fast of the night. After breakfast it increased steadily for two or three 
hours, and attained about 1° C. (1.8° F.) above the temperature of the 
early morning. 

By 1 o'clock, p. m., it had generally receded again about 0.4° C. or from 
half to three-quarters of a degree F. If dinner was then taken, in half 
an hour it was perceptibly increasing and continued to do so for the next 
three hours, reaching its climax about the middle of the afternoon, when it 
would be from 1.1° to 1.4° C. (2° to 2.5° F.) higher than in the early 

. * Se-> Experimental Inquiries, etc., in the North- Western Med and Surg. Journal, Vol. IV, pa -e 
196, 1851, by N. S. Davis. 



30 GENERAL PROCESSES AND COMPLEX FUNCTION?. 

morning. From that time it declined very slowly until the usual time for 
a light supper, after which it again increased moderately for two or three 
hours. These observations fully established the fact that the temperature 
of the body does not depend on kind or quality of the food, but 
directly on the activity of the processes of assimilation and nutrition. 
Indeed, it appeared that when the individual was restricted tor three days 
to a diet exclusively carbonaceous, the average temperature was slightly 
less than during confinement for a similar period to a diet exclusively 
nitrogenous. It was further ascertained that some of those articles which 
have been represented as pre-eminently respiratory food, alcohol for exam- 
ple, when taken into the system, induced a positive reduction of the tem- 
perature below the natural standard. While the changes in matter taking 
place during the active processes of digestion, assimilation and nutrition, 
cause the evolution of heat tending to increase the temperature of the 
body, the processes of disintegration and excretion produce the opposite 
effect. 

More especially is this true of those excretions that pass through the 
skin and lungs. In the natural condition of the system, these pass off prin- 
cipally in the form of gases and aqueous vapor. If you remember the 
large amount of free heat rendered latent by the conversion of fluids, and 
especially water, into vapor ; and that this process is constantly taking 
place from the whole cutaneous and pulmonary surfaces, you will not fail 
to appreciate the actively cooling effect upon the temperature of the whole 
body by such process. In view of the teachings of the past, and of the 
language of many of the books you study at present, it may sound to you 
strangely, when I speak of respiration as a cooling process. Yet that it 
is so, is not only apparent from the well-known fact that the fluid constant- 
ly bathing the extensive mucous membrane lining the whole extent of the 
respiratory passages is being constantly converted into vapor and being 
exhaled ; but also from the additional fact that both man and the lower 
orders of animals instinctively increase the frequency of respiration when 
too warm, and diminish it when too cold. And purely instinctive move- 
ments are believed to be always in harmony with physiological laws. 
Have you noted, gentlemen, your own habits in regard to this subject? 
While sitting here in a warm room, you breathe freely from fourteen to 
eighteen times per minute. But when the lecture is ended and you pass 
out on a cold winter day, do you continue the same rate of breathing, or 
do you almost unconsciously shrug your shoulders, draw your overcoats 
around you, and so far stifle your respirations that they will not average 
ten per minute? Again, look at the dog on your door-step on a hot sum- 
mer day. His mouth is open, his tongue out, and he is breathing as fast 
as he can. But you never saw him do the same thing on a cold day, unless 
in immediate connection with excessive exercise. And many an ox has 
been whipped for endeavoring to cool himself on a hot day by putting out 
his tongue and breathing fast, or " lolling," as his unlearned driver would 
call it. 

The same indications are afforded by the natural variations in the cuta- 
neous function. When the surrounding atmosphere is warm, tending to 
accumulate heat in the body, the skin relaxes and the conversion of the 
cutaneous fluid into vapor increases. In other words, perspiration is in- 
creased. When the surrounding atmosphere is cold, just the opposite 
effect on the function of the skin is induced. 

So also in diseased or morbid states, when the excretory function of the 
lungs, skin and kidneys is diminished, the temperature of the body in- 
creases; not because there is a more rapid evolution of heat, but simply on 



GENERAL PROCESSES AND COMPLEX FUNCTIONS. 31 

account of the diminution of those processes or functions by which the free 
heat is rendered latent and conveyed away. 

You cannot study too carefully the topics presented in this and the pre- 
ceding' lectures. To comprehend clearly the primary tissues, endowed 
with ti eir elementary properties; the primary functions each perform; and 
trace their combination to form more complex organs, and groups of organs, 
each working for the accomplishment of a given purpose, yet each bearing 
such relation to the o'h3rs that a disturbance of the function of one in- 
volves directly or indirectly the functions of all the rest, is the only way 
to gain any clear conception of what is meant by nature, as used in medi- 
cal parlance. From the days of Hippocrates to the present time, this word 
" nature " has occupied a prominent place in the literature of our profes- 
sion. In all ages, it has been clothed with the attributes of intelligent 
personality, and sometimes almost those of deity. Hence the expressions, 
"the powers of nature," the "efforts of nature," the "vis medicairix 
naturce," etc. We are told that nature does this and that, at almost 
every turn, and yet very few have attempted to explain what they meant 
by nature. One who in our time has written much in eulogy of nature, 
and her power to heal disease, and has correspondingly endeavored to be- 
little the value of art, defines his favorite goddess thus: "Nature, in med- 
ical language, means a trust in the reactions of the living system against 
ordinary normal impressions."* 

According to this definition, nature is not a physical power or function, 
but a simple mental act- -an exercise of faith or trust. Comment on such 
a definition is unnecessary. But suppose the author of this definition 
meant that nature consisted, not in the mental act of trust or faith, but in 
the "reactions of the living system against ordinary normal impressions," 
the question would then arise, what are these reactions? If they are any- 
thing more than shadows of the imagintion; and if the phrase, "reactions 
of the living system against ordinary normal impressions," means anything 
more than a rhetorical display of words to cover ignorance, such reactions 
must consist of nothing more than the actions induced in the various 
structures and organs by the impression of ordinary exterior agents, as 
food, air, light, etc. The impression of food upon the digestive apparatus, 
excites activity in certain secretory and muscular structures by which such 
food is both dissolved and moved onward, until its ingredients are fitted 
for addition to the tissues. 

The presence of such prepared material in the blood makes a normal 
impression on the properties of the tissues and the resulting action con- 
stitutes nutrition or the active addition of the newly prepared material 
to the structures. So the impression of oxygen in the arterial blood of 
the systemic capillaries, on the same properties of the different structures 
causes the action, or reactions if you prefer, constituting: disintegration. 
So, too, the same agent, reaching through the same medium, the various 
nervous centers by its normal impression on the properties of the nerve 
structure, causes that action which is styled nerve-force or innervation. 
The presence of the materials for constituting urine in the blood, making 
a normal impression on the properties of the secreting cells of the kidneys 
causes such action as actively combines these materials into urine and 
passes it out of the system. 

So of all the other secreting organs. But let us go a step further, and 
we shall find that the various tissues and organs are not only capable of 
acting or reacting against ordinary normal impressions, but also against 

*01iver Wendell Holmes. 



32 GENERAL PROCESSES AND COMPLEX FUNCTIONS. 

many impressions of an abnormal character. As I have already said, 
agents may enter the blood with the ingesta, either through the digestive 
or respiratory organs, which are not capable of being used in nutrition or 
in the natural process of disintegration, but which are capable of making 
an abnormal impression on the properties of the tissues generally, or on 
those of some particular organ. And these abnormal impressions cause 
unnatural actions, either in the whole body (general disease) or in the 
particular organ for which the agent had a special affinity (local disease.) 
Hence, Dr. Holmes defines disease to be the " reactions of the living sys- 
tem against abnormal impressions." But every foreign agent that gains 
access to the tissues through the medium of the blood, and makes an 
abnormal impression, is net followed by disease. On the contrary, many 
of these agents bear such a relation to someone of the excreting organs 
that they are rapidly separated with the proper secretion of such organ, 
and no morbid action results, thus presenting one of the chief conservative 
powers of the living body. Indeed, if we put this ability of the different 
excretory organs and structures to eliminate from the blood such elements 
as are foreign to its composition, with the power of certain organs to take 
on increased action in temporary compensation for deficient action in 
others, we shall have a correct idea of the true vis medicatrix, or rather 
vis conservatrix naturve. If you choose thus to use the word nature, with 
the definite understanding that it means simply the natural activity of the 
aggregate structures and organs of the body and their relations to each 
other, there is no objection to such use. It is a convenient and familiar 
word, and may be used to express the aggregate activities of a complex 
living body, as properly as any other in our language. So, too, if when 
you use the expressions, efforts of nature, powers of nature, vis medicatrix 
naturce, etc., you simply mean the action of some organ to eliminate mor- 
bid material, or to compensate for the deficient action of some other organ 
or the sedative effect of some retained excretion in overcoming the 
morbid excitability and muscular spasm that had caused its re- 
tention, there is no objection to such use. But when "na- 
ture" is installed in the human system as a personal entity, and 
clothed with attributes of intelligence, and the phenomena of disease rep- 
resented as the efforts of such nature to resist some morbid impression, 
and consequently not to be interfered with by art, it becomes not merely 
a fanciful goddess, but a positive hindrance to the advancement of prac- 
tical medicine. 



MEDICINES AND THERAPEUTIC PURPOSES. 33 



LECTURE IV. 

What are Medicines— What the Distinctions Between Food and Medicines— Their Classification for 
Therapeutic Purposes— Etiolcgy. 

HAVING, in the preceding lectures endeavored to explain, as famil- 
iarly as possible, the nature and conditions of health and disease in 
the living human body, I must next direct your attention to some thoughts 
on the nature and modus operandi of medicines. Remedial agents and 
influences properly embrace everything that can be made useful in allevi- 
ating or curing disease. 

In this sense, an encouraging word or cheerful look, is as much a rem- 
edial agent as a pill or powder from the apothecary. It is my intention, 
however, to limit your attention during the present hour to those material 
agents ordinaril} T styled medicines, reserving the consideration of other 
influences for another occasion. Medicines, in this restricted sense, are 
such agents as are capable of being introduced into the living system, and 
exerting a modifying influence over one or more of the properties or func- 
tions of the body, without being capable of assimilation or addition as 
nutritive matter, to any of the tissues. They may be introduced into 
the system through the digestive organs: through the lungs by inhalation; 
through the skin by absorption ; through the subcutaneous tissue by hy- 
podermic injections ; and by injection directly into the blood vessels. 
The first is the more common, and practically important method. But in 
whatever way the medicine is given, it enters the mass of the blood gen- 
erally unchanged in its composition, and induces its effects by passing 
with the blood into contact with the various structures of the body, and 
by such contact modifying either the properties or molecular changes, or 
both, in one or more of these structures. As a general rule they are also, 
sooner or later, eliminated from the blood by some of the excretory or- 
gans in so nearly the same condition as when they were introduced, that 
they can be readily detected by the proper chemical tests. The apparent 
exceptions to these rules are such alkalies and alkaline earths as are capa- 
ble of uniting directly with, and neutralizing acids, in the stomach before 
time for absorption. 

Even in these cases, however, the resulting compound is absorbed, and 
after passing the round of the circulation, is eliminated. The real excep- 
tions, are those agents that act directly on the structures to which they are 
applied, as in the case of sinapisms, blisters, caustics, etc. The disposi- 
tion on the part of many writers to call all the hydro-carbonaceous sub- 
stances respiratory food, and those substances that simply retard the pro- 
cess of disintegration, indirect food, has caused some confusion in regard 
to the distinction between food and medicine. It seems to me, however, 
that there are two plain and essential points of difference between these two 
classes of substances. The first is, that food proper never passes through 
the digestive and assimilative organs without important changes in com- 
position and form, and never re-appears in the excretions from either skin, 
kidneys or lungs, in the same form as it entered the system. For 
instance, the principal proximate elements of our food are starch, gum, 
sugar or glucose, fat or oils, gluten, casein, the fibrin and albumen of flesh, 
and the inorganic salts with which thev are united. If you note carefully 
3 



34 MEDICINES AND THERAPEUTIC PURPOSES. 

the successive changes of the food into chyme, chyle, lacteal fluid, etc., 
you will find all these proximate elements radically changed before they 
reach the mass of the arterial blood. And you will seek in vain for any 
one of them in the eliminations from the true excretory organs of the 
body. This is directly opposite to what I have represented to be the 
behavior of medicine in passing through the system. 

The second distinction is that food taken in a healthy state of the sys- 
tem always satiates the appetite for the time being; and that, too, in about 
the same quantity, without regard to the length of time it may have been 
used. For instance, if a person eats bread three times a day for 20 years, 
he is just as readily satisfied at the end of the time as he was at the be- 
ginning. Natural appetite or hunger is simply the demand for material 
to supply the waste of tissue, and every substance capable of assimilation 
when taken will satisfy that demand; and with that satisfaction ceases for 
the time being all relish for more. 

No such effect, however, will follow from the taking of materials that 
cannot be assimilated and added to the tissues by nutrition. Hence, daily 
observation shows that all those excitants, like the active principles of tea 
and coffee, and the anaesthetics or retarders of tissue-disintegration or 
waste, like alcohol, ether, chloroform, tobacco, etc., which have been 
classed by some as indirect food, have no power to satisfy except by me- 
chanical fullness of the stomach, or by such a degree of stupor or anresthe- 
sia as renders the individual for the time oblivious to further impressions. 

And all these articles, instead of producing the same effects in the same 
quantities for any number of years, as is the case with real food, invariably 
create a steadily increasing demand for more. You see the young lady 
who sipped daintily a cup of drink at her breakfast containing a tablespoon- 
ful of tea or coffee diluted with milk and water, ten or fifteen years later 
in life taking two cups at the same meal, each filled, not with milk and 
water flavored with a tablespoonful of tea, but with a strong infusion of tea 
or coffee. 

In like manner you see the young man at 18 years taking but one cigar 
and one glass of beer or wine per day, at 30 years consuming five or six 
cigars and as many drinks of beer, with now and then a glass of distilled 
spirits; and at 40 years he consumes a dozen cigars a day, and the num- 
ber of drinks is limited only by the quantity required to induce intoxica- 
tion. It is true that most, if not all, of these agents, used habitually, in- 
duce such a morbid condition of the stomach as to impair or destroy the 
appetite for proper food, but not for themselves. On the contrary, the 
latter grows stronger and stronger, more and more insatiable, until it too 
often becomes the ruling despot of the individual's life. Having thus de- 
fined what is meant by medicines as distinguished from food or aliments, 
1 will divide the whole into two great classes, as follows: 

First, those substances that are capable, by their presence in the blood, 
of modifying the properties common to all the tissues, in such a way as to 
produce a perceptible change in one or more of the general processes tak- 
ing place in the living body. These may be called general remedies, be- 
cause in modifying the general processes of nutrition, disintegration, and 
calorification, they necessarily influence in some degree all the functions 
of the animal economy. 

Second, those substances which, though introduced into the mass of the 
blood, exhibit an affinity for, or special action on, some particular organ or 
group of organs, and hence may be termed local remedies. 

The remedies included in the first class, may be arranged in four groups, 
called general stimulants or excitants; general tonics; general sedatives, 
and general alteratives. 



MEDICINES AND THERAPEUTIC PURPOSES. 35 

The first group embraces those substances that increase or exalt the 
susceptibility of the tissues simply — as tea, coffee, heat, oxygen, etc. 

The second includes such agents as are capable of increasing the play 
of vital affinity, either alone or in connection with a moderate increase of 
susceptibility, thereby giving an increased tonicity to the structures of the 
body, and generally an increase in the evolution of heat. To this group 
belong the preparations of iron, the mineral acids, guaiac, cantharides, 
phosphorus, many of the bitter vegetable alkaloids, etc. 

The third group embraces those agents that are capable of influencing 
either the susceptibility or the vital affinity, or both, in the opposite direc- 
tion from either of the preceding groups. That is, they either depress the 
susceptibility or impair the play of vital affinity, or both, at the same time. 
Consequently they diminish the molecular changes constituting nutrition, 
disintegration and secretion, and diminish both the evolution of heat and 
the capacity to receive impressions. To this group belong the hydrocy- 
anic and carbonic acids, the alkalies, the bromides, alcohol, ether, chloro- 
form, etc. Some of you may be surprised to see the alcoholic liquids 
included among the general sedatives. But all the experiments with alco- 
hol, from the days of Dr. Prout to the present time, have shown that while 
present in the blood it directly diminishes the temperature of the tissues, 
retards the atomic changes and the amount of eliminations, and diminishes 
the general susceptibility. If these effects do not constitute it a general 
organic sedative, it would be difficult to conceiye what should be ranked as 
such. 

The fourth group embraces such agents as are capable of modifying the 
properties of the tissues in a manner different from that of simple increase 
or diminution, and hence they are called alteratives. To this group belong 
iodine, mercury, arsenic, and their several preparations ; together with 
those agents that are supposed to neutralize poisons in the blood, or to 
prevent what are called zymotic changes in that fluid, such as the sul- 
phites, permanganates, carbolic acid, etc. 

These definitions are sufficient to give you a correct idea of what is 
meant by general remedies. 

They produce their effects, by acting on those elementary properties 
that are common to all the structures of the body. When they increase 
or exalt these properties they are stimulants and tonics. When they im- 
pair or depress, they are sedatives. When they modify the properties 
different from either increase or diminution, they are alteratives. 

But much the larger part of the remedies in the works on materia med- 
ica, belong to the second class, called local remedies. Quite a number 
even of those I have enumerated as general remedies will be found to 
possess, in addition, a direct local influence on some structure or organ. 
Thus, alcohol, by its presence in the blood, not only retards molecular 
changes throughout all the tissues as a general remedy, but like all true 
anaesthetics, it also diminishes locally the sensibility of the cerebro-spinal 
nervous centers. So, too, the tea and coffee, which have been ranked as 
general excitants, are capable of exerting a special local influence over 
certain portions of the nervous system, inducing wakefulness, palpitations, 
muscular tremors, etc. 

The group of remedies usually styled narcotics or soporifics, act more 
exclusively upon the brain and nervous centers. They directly diminish 
the sensibility of the nerve structures, and thereby relieve pain and favor 
sleep. In large doses they are capable of so completely suspending cere- 
bral sensibility as to cause coma and death. To this group belong opium, 
conium, hyoscyamus, lactuca, chloral, etc. Though all these agents dimin- 



36 MEDICINES AND THERAPEUTIC PURPOSES. 

ish cerebral sensibility, they do not all act alike. Thus, opium and its 
preparations cause dilatation of the smaller vessels of the nervous centers, 
and consequently increased accumulation of blood ; while hyoscyamus, 
belladonna and stramonium, cause contraction of the vessels, and thereby 
lessen the quantity of blood in the part. The action of the former is ac- 
companied by contraction of the pupil of the eyes, the latter by dilata- 
tion. Although the narcotics act primarily on the nervous tissues, yet by 
diminishing nerve seusibility, they secondarily diminish the influence of 
the nervous over the muscular structures, and thereby impair the respira- 
tory movements, circulation, the peristaltic motion of the bowels, and to 
some extent, the action of muscles of voluntary motion. 

Another class of agents when introduced into the system are capable of 
so modifying the circulation and properties in the cutaneous tissue as to 
cause a marked increase in the amount of exhalation from the surface ; 
and you call them diaphoretics or sudorifics. Another class exert a simi- 
lar influence on the mucous membrane of the respiratory passages, and 
you call them expectorants. Another class so influence the kidneys as to 
increase the quantity of urine secreted in a given time, and they are called 
diuretics. Still another class so modify the condition of the mucous mem- 
brane of the stomach and bowels and quicken the peristaltic motion, as 
to result in increased gastric and intestinal discharges, and they are called 
emetics and cathartics. The last four groups of remedies so alter the play 
of affinity in the organs on which they act as to increase secretory action. 
But there are remedies acting on the several organs in the opposite direc- 
tion; that is, in such a manner as to diminish secretion, and they are called 
astringents. Ao-ain, we have remedies of more or less value that do not 
directly modify either the structure or function of any part of the system, 
but which exert a purely chemical or mechanical influence. Thus, you may 
give acids to neutralize an excess of alkalies, either in the stomach or the 
blood; or alkalies to neutralize an excess of acids. Pepsin, hydrochloric 
acid, and many other substances, may be used as gastric solvents, when 
the natural gastric juice is deficient. 

There are also remedies of great value that do not properly belong 
either to the group of general organic sedatives or to the local narcotics. 
When properly administered they are capable of either diminishing the 
action of the heart and arteries, or of lessening the excitability of the 
cerebro-spinal and vaso-motor nervous centers. Those that appear to 
directly diminish the action of the heart and arteries, as the veratrum viride, 
aconite, digitalis, cold, and venesection, may be called vascular sedatives. 
Those that more prominently diminish the excitability of certain portions 
of the nervous apparatus, as the gelseminum, calabar bean, ergot, cimicif- 
uga, etc., may be styled nervous sedatives. 

In thus glancing rapidly over a therapeutic arrangement of remedial 
agents, it is no part of my purpose to enter upon the discussion of the 
modus operandi of medicine, but simply to give an outline of such a clas- 
sification as would correspond with the views expressed in the preceding 
lectures, concerning the nature and varieties of disease. If an accurate 
knowledge of physiology, or the conditions of function and structure, 
which constitute health, is essential as a starting point for acquiring 
a knowledge of disease, so is a thorough study of the nature and modus 
operandi of medicines essential as a preparation for their intelligent 
application in the treatment of disease. It is to be hoped, therefore, 
that all of you have given due attention to this branch of medical science 
during the earlier part of your studies. If not, I cannot too strongly urge 
upon you the importance of early supplying the deficiency. To note 



MEDICINES AND THERAPEUTIC PURPOSES. 37 

down formulas or prescriptions and apply them in the treatment of par- 
ticular diseases, simply because they were recommended by your teachers, 
without an accurate knowledge of each of their constituents and the spe- 
cial effect it is expected to produce, is to exhibit a blind dependence on 
authority degrading to the practitioner and dangerous to his patients. The 
conditions essential for the rational practice of medicine are a clear con- 
ception of the morbid conditions affecting the patient, an equally reliable 
knowledge of the nature and actions of medicines, and the discipline of 
mind necessary for accurately adjusting the latter to the fulfillment of the 
indications presented by the former. 

Etiology, — The general indications for the employment of remedial 
agents have been variously classified by different writers. The most sim- 
ple and convenient arrangement is, to consider first, those having for their 
object the removal of the cause or causes ; second, those arising from 
the essential pathology of the disease ; and third, those afforded by the 
secondary symptoms or consequences of the primary pathological condition. 

There are many morbid conditions which speedily cease by simply 
removing the causes that have induced them. There are others, which 
when fairly commenced, continue, though generally with less activity, after 
the causes have wholly ceased to act. Hence a correct knowledge of the 
nature and modus operandi of the causes capable of giving rise to partic- 
ular forms of disease is of great importance both to the physician and the 
community. Such knowledge not only enables the physician to treat 
individual cases of disease more successfully, but it enables both individ- 
uals and communities to adopt such sanitary and hygienic measures, as to 
greatly lessen the prevalence and fatality of many of the most important 
diseases to which our race is subject. 

Etiology, therefore, affords the only reliable foundation for the sanitary 
improvement of cities, populous towns, and even rural districts. To this 
department of medical science the world is indebted for all the advantages 
it derives from systems of sewerage, sea veneering, water supply, modes 
of ventilation, improved construction of dwellings, etc. 

And yet, there is no field in which more careful and patient labor is 
needed, or which will yield the laborer a richer reward. For though very 
much has been accomplished in ascertaining the special circumstances 
which favor the development of many morbid causes, the laws that gov- 
ern their diffusion, and their influence on the human system, yet but little 
progress has been made in the work of isolating and studying the nature, 
composition and properties of the several causes themselves. What has 
already been accomplished affords a broad foundation for most important 
sanitary improvements, both of an individual and municipal character, but 
what remains to be done in this department would add much to this foun- 
dation, and still more to our success in endeavoring to remove the causes 
acting injuriously on our individual patients. Diseases are often produced 
by the joint action of several causes, some of which act with feeble inten- 
sity, but continuously, through considerable periods of time. Others act 
more abruptly and with greater intensity. The first usually produce their 
effects slowly, merely modifying slightly the properties of the tissues or 
the functions of one or more organs, without at once developing the phe- 
nomena of active morbid action, and hence are called remote or predispos- 
ing causes. The second, acting with more intensity, and more directly de- 
veloping marked symptoms of disease, are called exciting causes. The 
division, however, is an artificial one, as nearly all the predisposing causes 
become direct exciting ones by simply increasing their intensity or pro- 
longing their duration. A more natural division of causes would be into 
external and internal. 



38 MEDICINES AND THERAPEUTIC PURPOSES. 

The first, embracing all agents and influences originating exterior to the 
living body, and capable of making an unnatural impression upon any of its 
parts ; and the second, such as originate within the living organization. 
The external causes are resolvable into two classes, name- 
ly: such as consist in changes, either in composition, quality 
or quantity of the natural ingesta, including under this latter term 
the air, water and food, and such as consist of agents not belonging to the 
natural ingesta, but capable of being received into the system through the 
same channels. I need hardly remind you that the air we breathe is com- 
posed of nitrogen, oxygen, ozone or active oxygen, carbonic acid, heat, 
and electricity, and that these constituents are subject to constant varia- 
tions. When such variations do not exceed certain limits they are con- 
sistent with a continuance of health in the animal economy. But when 
they are too abrupt, or extreme, they are productive of morbid conditions, 
often of the most dangerous character. The atmospheric elements most 
subject to such extreme changes are the ozone, heat and electricity. 

The most superficial observer knows that there is habitually, a wide dif- 
ference betweeu the character of diseases prevailing during the high tem- 
perature of summer and the low temperature of winter. The influence 
of heat in increasing the susceptibility and lessening the vital affinity or 
tonicity of living structures, is as apparent as its power to lessen the affin- 
ity by which the atoms of inorganic matter are held together. Many facts 
point to an intimate relation between extreme changes in the ozone, heat, 
electricity and aqueous vapor of the atmosphere, and the production of 
such diseases as influenza, catarrh, rheumatism, cholera, etc., and there is 
much need of further careful investigation in this direction. The second 
division of the external causes of disease, consisting of agents not natur- 
ally entering into the composition of air, water or food, but capable of 
being mixed with one or more of these and imbibed into the system through 
the same channels, arise mostly from the disintegration or decay of dead 
organic matter, both animal and vegetable. 

Hence, from a remote period in the history of medicine, they have been 
styled miasms. Idio-miasms, when the product of the decomposition of 
animal matter or animal excretions; and koino-miasms, when from the de- 
composition of vegetable matter. Until a comparatively recent period these 
deleterious products were very generally regarded as inorganic gaseous or 
chemical compounds, although so subtle and attenuated as to be ever 
eluding the best directed efforts of the chemist to isolate and examine 
them. By a few, however, like Copeland and Holland, in Europe, and J. 
K. Mitchell, in America, they were regarded as organic living germs, either 
vegetable or animal, fungi or animalcule. And since the general use of 
the microscope in medical investigations, the tendency to regard all the 
deleterious products of the decomposition of organic matter, as organized 
microscopic germs capable of self-propagation, and free diffusion in con- 
nection with the aqueous vapor of the atmosphere, has greatly increased 
throughout all ranks of the profession. Still there is very little agreement 
among the various observers, and the whole subject needs much more ex- 
tended and patient investigation. 

In all our researches with the microscope, concerning the nature of 
morbid causes, great care is required, lest we mistake the mere products 
or results of morbid action, for the causes. For instance, if we examine 
the surface of a sore on the skin, or of an ulcer in the mucous membrane 
of the mouth, and find it covered with fungi or vegetable germs, it does 
not necessarily follow that such fungi were the cause of the diseased spots 
in either place. Neither does it follow as a legitimate deduction that cer- 



MEDICINES AND THERAPEUTIC PURPOSES. 39 

tain violent epidemic diseases, as cholera, for example, arise from organic 
germs merely because such have been seen in the excretions. To furnish 
data for any legitimate deductions from this class of observations, they must 
be made at the very incipient indications of disease, and repeated at the dif- 
ferent stages of its progress, and after full recovery. Similar observations 
must also be made during the progress of other diseases aifecting the same 
organs or structures. The first series of observations are necessary to de- 
termine whether the supposed germs are always present in a given dis- 
ease ; and whether present in all stages of its progress, or only at certain 
periods. The second series are necessary to determine whether they are 
peculiar to the one disease or present in many and dissimilar diseases. 
One observer places a few specimens of cholera evacuations on the micro- 
scopic field, and observing certain organic germs, which on keeping a cer- 
tain length of time, develop into a species of fungus, and he straightway 
announces the discovery of the direct cause of cholera. Another places 
a specimen of the blood of a syphilitic patient on the microscopic field, 
and after patiently watching it for two or three days, a crop of living 
bodies make their appearance, and we have another grand pathological 
discovery. 

But just as the literature of the profession has become well filled with 
the important discoveries, and the many practical applications of which 
they are capable, behold some one else has also discovered that the special 
cholera fungus can be found as well in any serous intestinal evacuation, 
and that the so-called syphilitic germs are easily found in the blood of per- 
sons who never dreamed of having had that disease, either hereditary or 
acquired. It is thus that one set of investigators are constantly employed 
in correcting the errors of another class, and our literature is kept full of 
contradictory statements. 

Hasty generalization, or the deduction of important conclusions from 
imperfect and inadequate data, has ever been one of the greatest hindran- 
ces to genuine progress in both the science and the art of medicine. 

The second class of causes, those that originate in the living system, 
may be called mental and physical. That either deficient or excessive 
mental exercise, and either sudden or long continued action of the emo- 
tions and passions are capable of inducing morbid action in the physical 
structures of the body, is too well known to need illustration. That the 
physical processes of metamorphosis and disintegration may be so imper- 
fect or perverted as to cause unnatural products to be returned into the 
blood, or that the secretory action of one or more secreting organs may 
be so perverted as to cause the secretion to be unnatural in quantity or 
quality, and thereby become a cause of irritation and derangement, is 
equally obvious. This simple and hasty glance at the subject of etiology 
will be sufficient to show you both the importance of the indication for 
removing the causes of disease, and the practical difficulties in the way of 
fulfilling it. 

I stated that the second indication for the use of remedies in medical 
practice was founded on the nature of the disease. For instance, if the 
nature of the disease is such as to present increased activity and excite- 
ment, it indicates the use of soothing and sedative remedies; if increased 
sensibility and suffering, either narcotics or anesthetics; if impaired activ- 
ity and relaxation, excitants and tonics; if perverted vital affinity, alter- 
atives, etc. I need not tell you that a very large part of the skill and suc- 
cess of the practitioner will depend on the clearness of his appreciation of 
the nature of the morbid actions involved in any given case, and the ac- 
curacy with which he adjusts the remedial agents to meet the indications 
afforded thereby. 



40 EXAMINATION OF THE SICK. 

The third indication was founded on the secondary effects of the pri- 
mary disease, and the complications that supervene during its progress. 
The several organs and functions of the human body are so intimately 
connected with, and dependent on, each other, that it is almost impossible 
to have disease invade one without soon causing disturbance in others. And 
there are few individuals who do not have a greater susceptibility in some 
organs than in others, and hence, when attacked by general diseases, such 
sensitiveness often becomes so increased as to constitute active local dis- 
ease. And it often happens that the secondary affections become the most 
dangerous to the life of the patient. This is illustrated strikingly when 
any one of the principal excretory organs is involved. Thus, disease of 
the kidneys may be of such a nature as to prevent a proper elimination 
of urea, which being retained in the blood, poisons the cerebro-spinal 
nervous system, producing convulsions, coma and death. Or valvular dis- 
ease of the heart, by keeping up for a long time irregular circulation of 
the blood, causes general derangement of secretion, especially scantiness 
of urine and general dropsy. 

The practitioner, therefore, should study carefully the mutual relation 
and dependencies of one function on another, that he may be prepared, 
not only to treat the secondary derangements when they occur, but to 
enable him often to anticipate their occurrence by appropriate preventive 
measures. 

All details concerning etiology, pathology, diagnosis, and therapeutic 
action of medicine, will be given in connection with the consideration of 
particular diseases and groups of diseases ; my present object being sim- 
ply to give you such an outline as would challenge your attention, and sys- 
tematize your thoughts in relation to these topics. 



LECTURE V. 

The Examination of the Sick.— By Inspection, Oral Questions, Palpation or Touch; Instrumental 
Aid— The Principles of Diagnosis— Therapeutic Methods, etc. 

ONE of the most delicate and important duties of the physician is to ex- 
amine his patient. The object of such examination is to ascertain the 
location, extent, nature, stage of progress, and coincident derangements, 
of whatever disease or diseases may afflict the patient, together with the 
causes that may have been efficient either in producing it or perpetuating 
its existence. To accomplish this object fully, requires on the part of the 
practitioner, patience, kindness, gentleness of manipulation, close undi- 
vided attention, the mental discipline that gives quickness of perception 
and accuracy of comparison and induction, with that easy boldness which 
quietly assumes nothing to be immodest that is necessary for a full under- 
standing of the nature and extent of the disease, and yet which sacredly 
avoids all not thus necessary. To place the patient at ease, and at the same 
time secure attention, it is best to commence the examination with a few 
leading questions, such as, "How long have you been unwell ?" " How did 
your sickness commence ?" " Do you suffer much pain; and if so, where?" 
" Is it sharp, dull, burning, constant, or paroxysmal ? " 



EXAMINATION OF THE SICK. 41 

Having thus introduced the examination far enough to allow any feel- 
ing of trepidation or embarrassment that might have been felt by the 
patient, to have subsided, and at the same time to have obtained an out- 
line of his particular suffering, you should, without apparent design, pass 
directly to a methodical examination so complete as to elicit a correct 
knowledge of all the important functions and processes performed in the 
system. By simple inspection you observe the physiognomy or expression, 
the hue of the skin, the position or attitude, voluntary and involuntary 
movements, general contour or relative development of parts, and the par- 
ticular appearance of the tongue, with such other parts as may be the seat 
of special complaint. All this, except the two last items, may be accom- 
plished while proceeding with the oral part of the examination. 

After the leading introductory questions already suggested, the further 
prosecution of the oral examination should take such direction as to elicit 
as full an account of the several important functions as the patient is capa- 
ble of giving. Perhaps the most natural and easy method is to interro- 
gate consecutively concerning the organs engaged in the work of digestion, 
assimilation and nutrition; those engaged in the opposite processes of dis- 
integration and excretion; then those constituting the nervous system, both 
cerebro-spinal and ganglionic; and finally, those concerned in re-produc- 
tion, especially in females past the age of puberty. When the patient is 
too young or too sick to answer properly the necessary inquiries, the same 
should be directed to the nurse or whoever has immediate care of the pa- 
tient. There are some diseases, like those of a typhoid character, that al- 
ways blunt more or less the sensibilities of the patient, and often render 
the manifestations of mind so inactive as to cause very imperfect or er- 
roneous answers to be given, In other cases we have just the opposite, 
namely, such an increase of nervous sensitiveness as to cause the most ex- 
travagant expressions and the wildest exaggerations. It is proper and de- 
sirable always to have the nurse or some reliable member of the family 
present during the examination of such patients, because they will greatly 
assist in correcting erroneous statements and in supplying defects in the 
patient's memory. And it is a good rule in all delicate cases, and such as 
involve apparent mental derangement, to have a free, confidential inter- 
view with the nurse alone, during which you can canvass the statements 
and condition of the patient, without danger of exciting either his suspi- 
cions or his anger. I need not say this should be done entirely out of the 
sight and hearing of the patient. Nothing so quickly excites the fears or 
the suspicions of a conscious patient, as private conversation or whispering 
in his room. All conversation in the presence of the sick should be in a 
mild, kindly tone of voice, just loud enough to be easily understood, but 
wholly free from all abrupt and boisterous qualities. 

The correctness of the information obtained from patients will depend 
much on the manner in which questions are asked. If they are too gen- 
eral in their character, the patient will often fail to comprehend their full 
meaning, and give erroneous answers in consequence. For instance, many 
when asked if their food digests well, answer promptly, yes; and yet when 
asked more particularly, acknowledge that the food often lies heavy in the 
stomach after eating, or that they have frequent belching of gases, and 
sometimes acid eructations. So, too, in regard to excretions. I have seen 
many patients who, when asked " if their bowels were regular ? " answered 
without any hesitation, "Yes, they were all right." But when asked spe- 
cifically how often they had a fecal evacuation, some said once in three or 
four days ; others, three or four times every day; while others said once a 
day. The better way is to ask directly how often the patient has an evac- 



42 EXAMINATION OF THE SICK. 

uation from the bowels ? and what is the color and consistency of the 
evacuation ? The same rule is still more necessary in obtaining a knowl- 
edge of the renal secretion. Unless their attention has been previously 
called to the subject, many patients will not be able to give a reliable 
statement either as to the quantity or quality of the urine, but will answer 
in general terms that they think it is about natural. Others will say they 
" make a great deal more " than natural, when they really make it very 
often, but only a little at a time. Patients laboring under low forms of 
fever and paralytic affections, not unfrequently have either partial or com- 
plete paralysis of the muscular coat of the bladder. This is liable to 
cause — first, retention until a certain degree of distention of the bladder, 
and then dribbling so as to keep the clothing wet, or the passage of only 
a few spoonfulls at a time. In all such cases, in addition to careful inqui- 
ries of the nurse, the physician should daily examine the hypogastric re- 
gion sufficient to determine whether the bladder is distended or not. I 
have known a neglect of this latter rule to lead to several serious mis- 
takes. It is only a few weeks since that I was requested to see a young 
man reported' to be very dangerously sick from disease of the brain. On 
calling at the house, I met the attending physician, and after listening to 
a brief history of the case, entered the sick man's room. The patient was 
entirely comatose ; chin dropped ; pupils a little dilated ; breathing irreg- 
ular ; skin clammy ; pulse frequent and very feeble ; and frequent irregu- 
lar muscular twitchings. The latter with a strong urinous odor about the 
bed, caused me to inquire whether the patient had passed his water regu- 
larly. The attending physician answered in the affirmative. Turning to 
the nurse, I asked when he passed his water last ? Her answer was, " he 
passes it every little while, and his bed is wet now." "How long has he 
passed his water in the bed?" I inquired, at the same time passing my 
hand down over the region of the bladder. " Three days" was her reply. 
The hand at once detected a great degree of fullness in the hypogastrium, 
which further examination proved to be owing to the presence of a bladder 
so much distended that its fundus reached the umbilicus. The introduc- 
tion of a catheter gave exit to an ordinary chamber vessel full of ammoni- 
acal urine. The attending physician, not a little chagrined, excused him- 
self by saying he had not examined the region of the bladder because the 
nurse had assured him every day that the patient had passed his water 
freely. In most cases of chronic disease presenting obscure questions in 
relation to their pathology, and especially if accompanied by serous or 
dropsical effusions, the physician should directly examine the urine, aided 
both by chemical tests and the microscope. 

Palpation or Touch. — While the acquisition of an easy, systematic 
and accurate method of oral examination is of great importance to the 
physician, it is never sufficient to give him a full and correct knowledge of 
the condition of his patient, without the aid of direct contact or touch. 
By the latter we gain a knowledge of the temperature and other qualities 
of the skin; the state of the circulation as indicated by the force, frequency 
and regularity of the pulse; the fullness and regularity of respiration; the 
tension or flaccidity of muscles; the existence of hyperesthesia and anaesthe- 
sia, the existence or non-existence of indurations, enlargements, tumors, 
abscesses, dropsical effusions, etc.; and the physical condition of the parts 
within the chest and the abdomen. In young children, and in patients of 
all ages, whose mental perceptions are disordered by disease, direct physi- 
cal examination, coupled with inspection, constitute our chief means for 
acquiring a knowledge of the morbid conditions under which they may be 
laboring. 



EXAMINATION OF THE SICK. 43 

Instrumental Aid. — To render this part of the examination of patients 
more complete, various instruments have been constructed, some of which 
are of great practical value. The ophthalmoscope, otoscope, rhinoscope, 
laryngoscope, stethoscope, microscope, sphygmograph, thermometer, urin- 
ouieter, speculums, with test-tubes, spirit lamp, and chemical re-agents, con- 
stitute the chief instruments which the physician of to-day may bring to 
his aid in determining the existence, nature, stage of progress, and ten- 
dencies of disease. I do not say that a physician cannot acquire skill, and 
even superior skill, both in the diagnosis and treatment of disease, without 
familiarity with the use of many, and perhaps all of these instruments. 
And jret it must be admitted that each one of them, properly used, is capa- 
ble of adding both to the extent and accuracy of our knowledge concern- 
ing the morbid conditions it is designed to aid in investigating. It is de- 
sirable, therefore, that every general practitioner should be familiar with 
the use of all these instruments, and as far as practicable, keep them con- 
stantly within his reach. No detailed descriptions or illustrative drawings 
can give you an adequate knowledge of the articles themselves, or of their 
practical application. Such knowledge can be obtained only by direct ex- 
amination and actual clinical use. Happily for you as a class, the daily 
hospital and dispensary clinics, which constitute a prominent part of the 
course of instruction in this institution, will give you ample opportunities 
for becoming acquainted, individually, with the practical application of 
every instrument and appliance that may aid in the examination and treat- 
ment of the sick. As already intimated, the primary object of all our ex- 
aminations of the sick, is to ascertain whether they are afflicted by disease, 
and if so, its nature, extent, duration, etc. — in other words, to arrive at as 
full and complete a diagnosis as possible. 

But what constitutes a complete diagnosis ? Certainly not the mere 
classification or naming of the disease ; for a very superficial examination 
may enable the practitioner to determine that a patient has typhoid fever, 
pneumonia or rheumatism, and yet leave him w r ith a very imperfect knowl- 
edge of the pathological changes that had taken place in the solids and 
fluids of the body. A full and practical diagnosis in any given case em- 
braces, first, a knowledge of the general nature of the disease ; second, 
the pathological changes that have taken place, which determines the 
stage of advancement ; third, the nature and extent of the complications, 
if any, that have supervened ; and fourth, the physical and mental condi- 
tion and habits of the patient prior to the present sickness. The first 
of these items gained, will enable you to name the disease ; the second 
and third, to clearly comprehend the present pathological condition of the 
patient, and found thereon rational indications for treatment ; while the 
fourth, will often enable you to anticipate the tendency or direction which 
other changes will take, during the further progress of the case. 

The making of a full practical diagnosis is, therefore, the most impor- 
tant, and often the most perplexing of all the duties devolving on the med- 
ical practitioner. If he succeeds in obtaining a clear and correct knowl- 
edge of the nature, progress and tendencies of the disease under which 
his patient is laboring, it requires but a short and easy process of induc- 
tion to arrive at the rational indications for treatment. That is, to 
determine what needs to be done for the purpose of either mitigating or 
curing the disease, and re-establishing the health of the patient. And 
having determined thus logically the indications for treatment which the 
case requires, a competent knowledge of the principles of hygiene, and of 
the materia medica, will readily suggest the best means for fulfilling the 
indications presented. I say a competent knowledge of the principles of 



44 EXAMINATION OF THE SICK. 

hygiene, as well as of materia medica, because I hope none of you will 
make so great a mistake as to suppose the treatment of disease consists 
solely in the administration of drugs. 

A large part of the diseases coming under the care of the physician are 
caused by errors in diet, drinks, clothing, ventilation, and other matters in- 
cluded under the term hygiene; and no one can attain the highest degree 
of success as a practitioner who does not fully appreciate the importance 
of careful attention to the hygienic influences affecting his patients. 

The object of such attention is twofold, namely: to remove or correct such 
erroneous habits and conditions as may be still acting as causes; and the 
substitution of such as will positively aid in the restoration of the patient. 
A comfortable temperature; a sufficient supply of fresh, pure air; clean 
linens; a careful adaptation of the quantity and quality of food and drink to 
the capacity of the digestive organs to receive and assimilate it; and a quiet, 
cheerful, hopeful mental influence, are hygienic conditions of universal 
applicability in the management of the sick. I by no means approve of 
the modern doctrine of expectancy, which assumes that diseases must run 
their natural course, and that art can do little more than properly regulate 
the hygienic- conditions of the patient, and leave the rest to that intangi- 
ble something called nature. 

And yet I cannot too strongly urge upon you the importance of making 
yourselves thoroughly familiar with the facts and principles of public and 
personal hygiene, and constant attention to their application in the daily 
routine of practice. It would not be inappropriate to represent hygiene 
proper as bearing much the same relation to materia medica that physi- 
ology does to pathology. 

Therapeutic Methods. — Before closing this lecture, 1 must invite your 
attention to a few thoughts concerning the principal therapeutic methods, 
or systems, as they are sometimes called, that have found advocates among 
the leading members of the profession in this and the preceding genera- 
tions. Since the earliest periods of medical history, therapeutics, or the 
application of remedies in the treatment of disease, have been made to 
conform more or less closely to the co-existing ideas or doctrines in rela- 
tion to the nature of disease itself. When the nature and phenomena of 
diseases were regarded as dependent on certain chemical processes called 
concoction, fermentation, crisis, etc., the prevalent therapeutic system was 
founded on corresponding chemical notions, and had for its leading objects 
the hastening of the supposed concoctions, the maturing of the morbid 
humors, and their expulsion or neutralization. 

When the theories of vitalism gained the ascendancy, and all diseases 
were regarded as involving either debility (direct or indirect), or irrita- 
tion, the prevalent therapeutic ideas were soon found aggregated into two 
leading and opposing systems. The one, founded on the pathological doe- 
trine of debility, had for its leading object stimulation. The other, sug- 
gested by the idea of irritation, excitement, etc., had for its purposes dimi- 
nution of excitement by sedation and evacuation, and hence popularly 
termed antiphlogistic. During the first quarter of the present century the 
pathological doctrines of irritation and inflammation gained their most 
complete control over the mind and practice of the profession. Almost 
every morbid condition was referred to one or the other of these processes ; 
and as a consequence, bleeding, general and local, emetics, purgatives and 
alteratives, were in constant requisition in the treatment of even the most 
trivial ailments. But coincident with this supremacy of the antiphlogistic 
method in therapeutics, came the rapid development of organic chemistry, 
the application of the microscope to the study of minute anatomy, both 



EXAMINATION OF .THE SICK. 45 

healthy and morbid, and the discovery of the fact that many acute dis- 
eases were self-limited in duration, and capable of progressing to recov- 
ery without the active interference of art. By the first, our knowledge of 
the composition and properties of the various morbid products, whether 
in the tissues, the blood, or the secretions, was greatly increased ; and the 
doctrines of exclusive vitalism began to yield to a recognition of zymotic 
and blood diseases. By the second, histological investigations were pushed 
in every direction, unfolding the minute anatomy of all structures, healthy 
and morbid, and culminating in the doctrine of cell growth as the basis 
of organic structures, and in the cellular pathology of Virchow. 

By the third, a distrust or skepticism concerning the curative powers 
of medicines was rapidly engendered, and a confidence in the restorative 
processes of nature correspondingly increased. 

This tendency soon found marked expression in the writings of Jacob 
Bigelow, John Forbes, O. W. Holmes, and others, and did not stop until 
it had effectually checked the heroic use of active remedial agents that 
had been developed under the preceding doctrines of inflammation and 
antiphlogistic therapeutics. Under these various influences, the former 
theories or systems of medicine have been abandoned, and yet no other 
one law, either pathological or therapeutical, has succeeded in gaining 
any general control over the professional mind. The last twenty years 
have been characterized by great activity in the accumulation of facts, 
and the multiplication of experiments, in almost every department of med- 
ical science. 

Indeed, it may be regarded as pre-eminently an era of observation and 
independent research, untrammeled by authority. And yet, you must 
not imagine that the present, with all its independence of thought, ac- 
tivity of observation, and vast accumulation of facts, is free from the influ- 
ence of fanciful theories and bold attempts at generalization. The human 
mind, in the present, as in all the ages of the past, is not only prone to 
generalize — to frame hypotheses based on a limited number of facts, but 
having gained a favorite standpoint, to see all else through light radiating 
from that focus. Hence the enthusiastic microscopist, after tracing all 
organized structures to formation out of primary cells; and structural 
changes, whether healthy or morbid, to normal and abnormal cell evolu- 
tions, naturally enters upon the study of etiology with the favorite instru- 
ment in hand, and soon finds organic germs, either animal or vegetable, in 
the blood, the secretions or the excretions of patients laboring under al- 
most every variety of diserse. And these germs are at once heralded as 
the efficient cause of the diseases with which they are associated. It re- 
quires but a hasty glance over the medical literature of the day to see that 
we have a large class of writers and investigators who are already refer- 
ring the origin and propagation of cholera, yellow fever, influenza and 
other epidemics, as well as many of the endemics, to organic germs. As 
all these organic germs have their definite periods of development, ma- 
turity, propagation, and decline, it is consistent and natural to infer that 
the_ diseases to which they give rise should also have a definite course to 
run, which cannot be materially altered by treatment. Hence the thera- 
peutic doctrines of this class are fairly expressed in the words palliation 
and expectancy, while they place great emphasis on hygiene and prevent- 
ive measures. Another class, with their standpoint of observation in the 
laboratory of the organic chemist, see in the living system only a com- 
plicated series of chemical actions and reactions taking place in the blood, 
and between the constituents of that fluid and the organized tissues. So 
long as these processes are well balanced, the evolution of heat, electricity 



46 EXAMINATION OF THE SICK. 

and nerve-force is natural, and health is preserved. But when, from any 
cause, the equilibrium is disturbed by some change in the chemical (actors, 
the results are also abnormal and disease is established. By this class we 
have all the ancient doctrines of humoralism revived under the modern 
terms septicaemia, zymosis, blood degeneration, etc. Their therapeutics 
are, of course, largely antiseptic and antidotal. 

A third class have their standpoint of observation in the physiology and 
pathology of the nervous tissues, and they find little apparent difficulty in 
satisfying themselves, at least, that almost every variety of action that 
takes place in living matter, whether healthy or morbid, is under the con- 
trol of nervous influence.* With such, the chief end of therapeutics is to 
modify the various morbid conditions of structure and function in nerve 
matter. 

But a fourth, and much larger class than either of the foregoing, pos- 
sessing no definite scientific or theoretical standpoint of observation, being 
swayed by the general current of reaction from the antiphlogistic system, 
and captivated partly by the simplicity of the doctrine that all disease is 
a diminution of life,f and partly by the plausable eulogies of "nature" 
and her all-controlling powerj over disease, they have become essentially 
skeptical in therapeutics, and content to regulate the hygiene of the sick- 
room, amuse the patient with placebos, and wait for " nature " to cure 
the disease. Or, more properly, perhaps, wait for the disease to com- 
plete its course and disappear; for we find the greater part of this class, 
not only skeptical in regard to the curative powers of medicines, but also 
firm believers in the doctrine that diseases have an independent existence 
marked by growth, maturity and decline, which makes them in a great 
measure independent of the influence of medication. § At a period when 
investigations are pushed with so much vigor in every direction; when new 
facts are constantly appearing, and old facts are being presented in new 
aspects; and when so much that is recognized as a part of medical science 
is but partially or imperfectly known, it is not strange that our litera- 
ture should be filled with contradictions, better calculated to bewilder than 
to enlighten the student. 

And yet, gentlemen, if you will patiently study the views I have pre- 
sented to you in the preceding lectures, concerning the elementary forms 
of disease, the methods of investigation, the indications for treatment, and 
the principles governing the application of remedies, you will be able to 
follow me in the study of special pathology and therapeutics in such a 
way as to become rational and efficient practitioners; neither investing 
disease with the attributes of independent existence and self-determined 
duration, nor regarding the curative powers of medicine with a melancholy, 
vacilating skepticism. 

There is one fact in therapeutics that I wish to impress indelibly upon 
your minds. It is that the special influence of any and every remedial 
agent depends much upon the actual condition of the patient at the time 
it is administered. For instance, a remedy that, administered in health, or 
in some conditions of disease, would produce a direct sedative or debilita- 
ting influence, if given in some other conditions, would result in relieving 
the sense of oppression and weakness, and adding to the strength of the 
patient. All writers class veratrum viride, aconite, and digitalis among 
the sedatives, yet I have seen many patients so debilitated by insufficient 
oxygenation and decarbonization of the blood, caused by an irregular, trem- 

* See Brown-Sequard's lecture in the Toner course, at Washington, D. C, 1873. 

f See Chambers'. 

X See Essays of Bisrelow, Forbes and Holmes. 

'i See Dr. Gibson's Address before the British Medical Association in 1870. 



EXAMINATION OF THE SICK. 47 

ulcms action of the heart, that they could not walk across their room, who, 
when placed enough under the influence of these articles to render the 
heart slow and steady in its beat, could walk or ride with ease. I have 
seen patients in the first stage of pneumonia, with the face deeply suffused 
with redness, the breathing short and oppressed, the pulse frequent and 
weak, and the feeling of prostration so marked that they were unable to 
rise from the bed, so relieved by one prompt, free bleeding that they could 
not only sit up, but walk about their room with ease. What are recog- 
nized as tonics and stimulants, given to the same patients in the same 
stage of the disease, instead of strengthening, would have added to the de- 
bility of the patients by increasing the local vascular fullness. Again, the 
same quantity of an anodyne or anaesthetic that might be required simply 
to render a patient comfortable when suffering from delirium tremens or 
severe neuralgia, might produce dangerous, or even fatal, effects, if given 
to the same patient when well, or the nervous system not disturbed. 
Hence, I repeat, that the general effect of any and every remedy will be 
determined very much by the condition of the patient at the time of its 
administration. And I can give you, gentlemen, no more important thera- 
peutic law, or general rule of action, than to so investigate every case 
as to gain a clear and definite conception of the existing pathological condi- 
tions, and then apply such remedies as are most accurately calculated to 
remove both the morbid conditions and the causes on which they depend, 
without regard to either nosological arrangements or classifications of the 
materia medica. "When the case is so obscure that a satisfactory idea of 
the actual morbid conditions cannot be obtained with all the. aids for 
making a proper diagnosis that are within our reach, then be content to 
palliate symptoms as they are presented from day to day, by mild means, 
rather than hazard doing positive injury by a blind exhibition of more 
active remedies. 



PART II. 

CONSIDERATION OF INDIVIDUAL DISEASES OR 
PRACTICE OF MEDICINE. 



LECTURE VI. 

Classification of Diseases— The Object to be Attained— Extended Nosological Arrangements "of 
Little Practical Value— The Simplest Classification the Best. 

HAVING in the preceding- lectures completed the discussion of those 
elementary principles and facts which are deemed important as an in- 
troduction to the study of special pathology and therapeutics, or practical 
medicine proper, I shall now enter upon the consideration of individual 
diseases and their treatment. 

To secure order or method in our progress, and avoid repetition, it will 
be necessary to form some classification by which those diseases having 
a number of important facts relating to their etiology, pathology, or symp- 
tomatology, in common, may be grouped together. At a former period in 
the history of medicine, great importance was attached to the subject of 
Nosology; and as much learning and skill were exhibited in arranging dis- 
eases into classes, orders, species, and varieties, as was shown by Linngeus 
in classifying the vegetable kingdom. You may find one of the most com- 
plete specimens of these extended nosological arrangements, in the great 
work entitled the " Study of Medicine," by Dr. John Mason Good. All 
such extensive and complicated arrangements, however, have been found 
imperfect and unprofitable. 

During the last quarter of a century, some writers have attempted to 
classify diseases in accordance with their supposed causes, calling one 
group Zymotic, another Parasitic, etc. Others have made anatomical 
structures the basis of their arrangement ; and still others have made the 
important organs and groups of organs the basis. But both these latter 
methods lead to the grouping together of diseases the most dissimilar in 
their nature, and our knowledge of etiology is too imperfect to render it 
reliable as the basis of a general classification. For our purposes the fol- 
lowing arrangement, which I sketch before you on the blackboard, will be 
found sufficient : 



CLASS I. 
GENERAL DISEASES. 



Sub-class I. Idiopathic fevers, JS^5f c e > 
or acute general diseases . . | ttj-^h 



:ive. 



f Of the Blood. 
Sub-class II. Constitutional ! 
diseases or chronic general ] 
diseases I0i Nutrition. • 

(48) 



CLASSIFICATION OF DISEASES, 49 



CLASS II. 
LOCAL DISEASES. 



Sub-class I., Inflammations. 
Sub-class II., Fluxes. 
Sub-class, III., Neuroses. 
Sub-class IV., Miscellaneous. 



You will see that I have arranged all diseases first into two great classes, 
simply denominated general and local. By a general disease I mean one 
whose primary or initial symptoms are such as to indicate disturbance of 
those properties and processes that are common to all the organs and 
structures of the body. When any morbific cause is permitted to act 
upon the living system in such a way as to disturb the general properties, 
susceptibility and vital affinity, it necessarily disturbs the processes of nu- 
trition, disintegration, and calorification; in other words, it develops at 
once symptoms of general disturbance. It is proper, therefore, to desig- 
nate the disease thus induced a general disease. 

On the other hand, when the primary symptoms of disease are limited 
to disturbance of the function of a single organ or group of organs, and 
the system generally remains undisturbed or becomes involved only sec- 
ondarily, the disease is called local. Nearly all of the more active or 
acute local affections so interfere with some important function as to in- 
duce more or less general disturbance during their progress. 

In like manner, all the general diseases are liable to become compli- 
cated with strictly local affections during some part of their course. 

The general diseases constituting the first class, may be conveniently 
divided into two sub-classes, which I shall call idiopathic fevers or acute 
general diseases, and constitutional or chronic general diseases. The 
first are essentially acute or active in their progress, self-limited in dura- 
tion, and accompanied by appreciable changes, both in the qualities of the 
blood and the properties and molecular changes of the tissues. The sec- 
ond, are not acute except in the development of local disease; not self 
limited in duration; and often existing for years without inducing appre- 
ciable changes in the blood or active disturbance of the more general pro 
cesses of the animal economy. The first, or febrile division, originates 
from such causes as are capable of diffusion in the atmosphere, probably 
in connection with aqueous vapor, and of suspension in water, or from 
changes, in one or more of the natural constituents of the atmosphere itself 
When the causes depend on certain local conditions, and are limited to 
certain geographical and geological districts, becoming active in the pro- 
duction of disease at certain parts of every year, they are termed endemic 
When they are developed to a state of activity at irregular intervals, with- 
out strict regard to geological formations, and causing disease to attack 
large numbers in any given community, they are called epidemic. 

The second, or constitutional division, have their origin from causes 
that generall} r act with feeble intensity, but persistently through long pe- 
riods of time, such as errors in diet, drinks, exercise, clothing, and heredi- 
tary influences. These may result in impoverishment of the blood, spa- 
noemia, from insufficient assimilation of food; or in rendering the blood 
impure by interfering with the processes of disintegration and excretion, 
thereby retaining the products of tissue metamorphosis until they excite 
irritation in particular structures, as in gout and rheumatism. Some of 
these causes may induce not merely insufficient but imperfect assimilation, 
and consequent perverted nutrition, as in scrofula and the various mor- 
bid growths and deposits. 

4 



50 CLASSIFICATION OF DISEASES. 

A closer study of this class of diseases will enable us to arrange them 
into two. groups; one, in which the prominent and constant characteristic 
condition is an unnatural or morbid state of the blood; and the other, 
in which the more prominent characteristic is altered nutrition and its 
results. 

The first group includes gout, rheumatism, and constitutional syphilis. 
The second, scrofula, tuberculosis, carcinoma, and leucocythaemia. 

That gout and rheumatism are results of retention in the blood of cer- 
tain chemical substances resulting from the processes of tissue metamor- 
phosis, and which in the healthy condition are excreted chiefly through 
the skin and kidneys, is now well understood. The abnormally acid con- 
dition of the fluids in rheumatism, and the excess of uric acid in the 
blood of patients afflicted with gout, clearly indicate the essential pathol- 
ogy of these affections, and fully justify their classification as blood dis- 
eases. The well-known fact that syphilis in all its stages originates from 
the primary introduction of a specific poison into the blood, renders any 
comments on its proper classification unnecessary. That these three forms 
of disease are constitutional ', is shown by increased susceptibility to at- 
attacks acquired by every new outbreak; the persistent tendency to be- 
come chronic, and the liability to hereditary transmission. 

Patients affected with any one of the second . group of constitutional 
diseases, present no uniform changes in the chemical constituents of their 
blood, or in the secretions directly eliminated from that fluid. When- 
ever changes from the natural condition are traceable in the blood of such 
patients, they relate to the organic ingredients derived from the process 
of assimilation, such as the albumen, fatty matter, and colorless corpuscles; 
and when local changes are manifested, they take the form of either caco- 
plastic deposits or morbid growths. The first are seen chiefly in scrofula 
and tuberculosis, and the last in carcinoma and leucocythgemia. Those 
of you who are familiar with that part of medical literature relating to the 
last named disease, may be surprised that I should place it in this group, 
as writers generally have represented it as pre-eminently a blood disease, 
on account of the existence of an excess of colorless corpuscles in that 
fluid. It is probable, however, that such excess of corpuscles is only an 
effect or symptom resulting from an error in the assimilative and nutritive 
processes, as I shall endeavor to show hereafter. 

The second general division of diseases, called local, may be conven- 
iently subdivided into four groups: which will be designated phlegmasia, 
or local inflammations; fluxes, or such as are characterized by excessive 
flow of fluids; neuroses, or non-inflammatory affections of nerve tissues; 
and miscellaneous, or unclassifiable cases. The individual inflammations 
receive names in accordance with the organs or structures they affect. 
Thus we have in the 

f Meningitis. 

Cranium -j Cerebritis. 

[ Cerebro -Spinal Meningitis, &c. 

Eye and Ear -j Opthalmia and Otitis. 



Chest 



Abdomen . 



Pleuritis. 

Pneumonia. 

Bronchitis. 

Carditis and Pericarditis. 

Gastritis. 
Enteritis. 
Peritonitis. 
Hepatitis. 
L Splenitis, &c. 



CLASSIFICATION OF DISEASES. 



51 



Felvis 



f C ' 



Skin 



Metritis. 
1 Vaginitis. 
I Cellulitis, &c. 

• Cutaneous Inflammations. 



The enumeration might be extended to the bones, muscles, nerves, 
blood-vessels, lymphatics, areolar tissue, and the skin, all of which are 
liable to attacks of inflammation; but the foregoing will sufficiently indi- 
cate the principle which governs the application of names to inflammation 
Id any of the structures or organs of the body. 

The word Jlux or Jinxes, which I have chosen to designate the second 
division of local diseases, may not appear altogether appropriate or free 
from liability to criticism. 

Yet I have not been able to choose a better one. The group of diseases 
included in this sub-class are all characterized by an undue exudation or 
effusion of fluids from some one or more of the structures of the body. The 
fluid effused may be only the water holding in solution more or less of the 
soluble constituents of the blood, or it may be the blood itself. The first 
may be denominated serous, and the second sanguineous, fluxes. 

The serous fluxes are again devisible into such as take place from free 
surfaces, and such as occur into shut sacs. The free surfaces consist 
chiefly of the cutaneous tissue covering the exterior of the body, and the 
mucous membranes lining the interior of the digestive apparatus. When 
the flow takes place from the former it is called diaphoresis; when from 
the latter it is called serous diarrhoea, cholera morbus or epidemic cholera, 
according to the degree of its severity. If the flow takes place into the 
shut sacs, consisting chiefly of the serous and synovial membranes, it 
having no outlet, accumulates, distends the sac, and constitutes what is 
usually styled dropsy. It is not limited, however, strictly to the mem- 
branous sacs, but may take place in the interstitial spaces of the areolar 
tissue and the parenchyma of some of the organs. 

The same remarks are applicable to the sanguineous fluxes. The blood 
may flow from a free surface like the mucous membranes of the respiratory 
organs, the alimentary canal, and the pelvic viscera and be at once dis- 
charged, or it may extravasate into the areolar tissues in different parts of 
the body, and be retained an indefinite period. The several diseases in- 
cluded in this subdivision may be conveniently tabulated as follows: 



FLUXES. 



\ Skin — Diaphoresis. 



''from free surfaces of 



Serous-* 



Mucous mem- 
branes . . 



f Serous diarrhoea 
\ Cholera morbus 



i. shut sacs 



serous mem- 
branes of 



[_ Epidemic cholera 

\ Brain — Hydrocephalus 
Lungs — Hydrothorax 
Heart — Hydropspericardii 
Abdomen — Ascites 

^Articulations — Synovial Dropsy 



L Interstitial tissues — (Edema or Anasarca 



f TSTostrils — Epistaxis 
| Lungs — Haemoptysis 
f from free sur- ] Stomach — Hamiateinesis 



Sanguineous 



faces of 



Bladder — Hsem aturia 
Uterus — Menorrhagia 
Intestines — Intestinal Hemorrhage 



(Jnto interstitial tissue — Hematocele, etc. 



52 GENERAL PATHOLOGY OF FEVERS. 

The third division of the second class of diseases, termed Neuroses, in- 
cludes all those morbid conditions of the nervous structures that are not 
strictly inflammatory in their nature. Pathological ly, they are suscepti- 
ble of arrangement into such as are accompanied by appreciable change 
of structure, altered nutrition ; and such as are manifest by disturbance of 
function only. Under the first head we might include atrophy, or defect- 
ive nutrition ; hypertrophy, or excessive nutrition ; disarrangement of 
atoms or cells, constituting softening ; hypertrophy of the connective tis- 
sue, with atrophy of nerve matter constituting sclerosis and metamorphp- 
sis of structure, as in fatty degeneration. 

Under the head of functional disturbances might be mentioned increas- 
ed sensibility — hyperesthesia ; diminished sensibility — anaesthesia ; per- 
verted sensibility — morbid sensations and tastes ; and corresponding alter- 
ations of transmissibility, inducing derangement of muscular action, such 
as rigidity, convulsions, and paralysis. At present, however, both the 
physiological and pathological conditions of the nerve structures are sub- 
jects of the most active investigation ; and the exact relations between 
clinical facts and symptoms, and the different pathological conditions 
just mentioned, are not sufficiently established to justify an attempt to 
maintain a strictly pathological classification of nervous diseases. 

Therefore, I shall follow the more common practice and arrange the af- 
fections of the nervous structures under the following heads : 

APOPLEXY, EPTLEPSr, CHOREA, 

CATALEPSY, CONVULSIONS, TETANUS, 

HYDROPHOBIA, HYSTERIA, PARALYSIS, 

HYPERESTHESIA, ANAESTHESIA, LOCOMOTER ATAXY, 

NEURALGIA, INSOMNIA, SUN-STROKE, 

DELIRIUM TREMENS, METHOMANIA, MENTAL DISORDERS. 

I have enumerated a fourth subdivision or groups of local diseases, and 
given to it the name of Miscellaneous, because, in the routine of general 
practice I have met with a number of morbid conditions so persistent and 
troublesome as to require much attention, and yet they could not be ap- 
propriately classified in either of the other divisions. These I shall de- 
scribe to you in the closing part of the present term. 



GENERAL DISEASES 



LECTURE VII. 

General Pathology of Fevers— Ancient and Modern Views Compared— The Unity, or Oneness of alJ 
Fevers, and their Diversity— Pathological Conditions Common to them all. 

IN the preceding lecture your attention was directed to a simple, general 
classification or grouping of diseases, convenient for use in the lecture- 
room. The first order, or sub-class of diseases named in that arrangement 
was the idiopathic fevers. It was then stated that the particular dis- 
eases included in this order could be conveniently grouped into three fam- 
ilies, each characterized by certain prominent phenomena distinguishing it 
from the others, and yet each presenting other important phenomena com- 
mon to the whole. In commencing the study of this important order of 



GENERAL PATHOLOGY OF FEVERS. Oo 

diseases, the first question that challenges our attention is the same which 
lias perplexed the minds of all medical philosophers from the days of Hip- 
pocrates to the present, namely: What is fever ? Dr. James Copland, 
author of the Dictionary of Practical Medicine, and one of the most philo- 
sophical of English writers, first defines fever by simply enumerating its 
more constant symptoms, as, u painful lassitude, debility of the corporeal 
and mental faculties, alterations of the animal heat and of the secreting 
functions, accelerated circulation, increased thirst, and abolition of the ap- 
petites." In another place he says, "Fever is a disease of all the vital en- 
dowments, functions, and faculties of the fluids, and of the whole organi- 
zation." Dr. William Aitken, a more recent English writer, collating 
largely from the writings of Virchow, Parkes, and Jenner, says: "Fever 
essentially consists in elevation of temperature, which must arise from an 
increased tissue change, and have its immediate cause in alterations of the 
nervous system." This, however, is simply returning to the brief defini- 
tion of Galen — " calor praeter naturam." 

Dr. George B. Wood, one of the best writers on practical medicine in 
this country, defines fever to be "an acute affection of the system, in which 
all the functions are more or less deranged ; the most striking phenomena 
being sensorial, or nervous irregularity, increased frequency of pulse, in- 
creased heat, and disinclination for food." Most of the writers of the 
present day make no attempt to give a special definition of fever, but pro- 
ceed directly to consider its history, symptoms, causes, effects and treat- 
ment. While Hippocrates and Galen regarded increased heat as the es- 
sence of fever, they attributed such increase to some morbid condition of 
the fluids of the body, which were then supposed to consist of bile, atra- 
bile, phlegm and blood. 

The active phenomena of the fever were supposed to result from the con- 
coctions taking place in the humors or fluids, and the efforts of nature 
to expel the morbid products. This was the ancient humoral doctrine, 
familiar to all students of medical history, that under some modification 
held sway over the professional mind until the time of Hoffman and Cul- 
len. The progress of anatomy and physiology had developed some knowl- 
edge of the special functions of the nervous structures and their influence 
over the blood-vessels; and Hoffman was one of the first to trace many 
of the more prominent symptoms of fever to a morbid condition of the 
nerves. Spasm of the capillaries under nervous influence he regarded as 
the first step in the development of fever; while the subsequent heat and 
arterial excitement was caused by the reaction or efforts of the system to 
overcome this spasm. 

Cullen enlarged, revised and moulded these crude ideas of Hoffman 
into a nervous theory of fever so plausible and popular that it soon gained 
complete supremacy over the doctrines of the Humoralists ; and so fully 
concentrated the attention of investigators and writers upon the functions 
of the solids or organized structures, that all theories of disease or morbid 
action soon became as exclusively solidistic as they had previously been hu- 
moral. Of course, the doctrines of Cullen were modified from time to 
time, with each important advance in the departments of physiology and 
organic chemistry, and yet it is not difficult to recognize some of them still 
holding an important place in the writings and teachings of many eminent 
members of the profession in our own time. Thus, Dr. John Eberle, au- 
thor of one of the earliest systematic works on Practical Medicine in this 
country, says : " The first link in the chain of morbid actions, which oc- 
cur in the development of fever, always commences in the nerves." * 

* See Eberle's Practice of Medicine, 2nd Ed. Vol. I, pg. 12. 



54 GENERAL PATHOLOGY OF FEVERS. 

Dr. George B. Wood, in his most excellent work on Practical Medicine, 
which for many years was one of the best text-books in our language, says: 
"Whether the fever is idiopathic or symptomatic, the first decided step 
towards its formation seems to be some morbid impression upon the nervous 
system, and this impression seems to be of a depressing nature."* It is 
by this supposed depressing influence on the nervous system that all this 
class of neuro-pathoio^sts endeavor to explain the formation of the initial 
chill or cold stage that ushers in most fevers, while the fever proper is rep- 
resented as the reaction of the system against this depression. But Dr. 
Wood was too close and accurate an observer at the bedside, not to rec- 
ognize the fact that there was something here more than mere nervous 
depression and consequent reaction. Hence, on the same page from 
which I have quoted, he adds, with characteristic candor: "We may thus 
partially explain the condition of the chill, but there is something more 
which we do not fathom; something in which the chill of fever differs from 
other instances of nervous depression." And in reference to the re-action, 
he adds: "But there is here also something more than mere re-action. 
There is the continued action of the cause, a diversified play of sympathies 
in one case, a widely pervading influence from some unknown agent in 
another; and fever is not purely, as some have maintained, the resilience 
of the depressed system." 

Dr. Southwood Smith, physician to the London Fever Hospital, and one 
of the ablest and most logical English writers, in the latter part of the first 
half of the present century, in his interesting w^ork on fevers, published 
in 1830, not only claims a unity or oneness in the essential pathology of 
all fevers, but he places that pathology in disturbance of the functions of 
the nervous, circulating, and secreting organs, not taking place simul- 
taneously but in an invariable order of sequence. Hence he says: "The 
order of events, then, is first, derangement in the nervous and sensorial 
functions; this is the invariable antecedent; secondly, derangement in 
the circulating function; this is the invariable sequent; and thirdly, de- 
rangement in the secretin a- and excreting* functions; this is the last re- 
suit in the succession of morbid changes."f Dr. Daniel Drake, in his 
valuable work on the Topography and Diseases of the interior valley of 
the North American Continent, does not discuss the pathology of fevers as 
a class, but in alluding to the modus operandi of the efficient cause of pe- 
riodical fevers, says: "The paroxysmal character, not less than the symp- 
toms that characterize this stage, shows that the function of innervation 
is deeply involved and embarrassed. We may, in fact, admit that it is 
the first affected. "J And again, in discussing the pathology of the ty- 
phous family of fevers, he says: "The history of the typhous fevers indi- 
cates an early, if not a primary , morbid state of the innervation^ which all . 
the phenomena declare to be one of adynamia with irritation, a failure of 
the vis nervosa with perversion; a degradation with abnormal molecular 
actions." § These allusions to some of the most eminent writers on prac- 
tical medicine, are sufficient to show that even to the present time, the 
doctrine that the first step or link in the chain of morbid actions taking- 
place in the development of idiopathic fevers, is a disturbance of the 
functions of the nervous system. Indeed, most medical writers appear to 
recognize no mode by which an impression can be made upon the organ- 
ized structures of the body, except by a primary action on the nerves. 
They appear to recognize no properties common to all tissues, by which 

* See Wood's Practice of Medicine, 5th Edition, Vol. I. p. 112. * 

fSee A Treatise on Fever by Southwood Smith, M. D. p. 62, 18H0. 
X See Drake on the Principal Diseases of the Interior \ alley, &^.,Vol. II, p. 51. 
I See idem, page 498. 



GENERAL PATHOLOGY OF FEVERS. 55 

they, like the primary germinal cell or aggregation of bioplasm, are capa- 
ble of receiving impressions and undergoing molecular changes, both 
healthy and morbid, independent of mere nervous influence. 

Indeed, Dr. Austin Flint, in writing on this subject, says directly: 
"There would seem to be, in fact, in the body only two anatomical sys- 
tems having relations so extensive as to be able to give rise to the train 
of morbid phenomena in fever, viz: the nervous system and the blood."* 
Yet he, like many of those who have written during the last two decades, 
places the primary morbid changes in the blood, rather than in the nervous 
structures. 

ff you examine carefully the current literature on this subject, you will 
find a large majority of the writers of our own time, referring all fevers 
to specific causes, such as organic germs or infectious miasms that gain 
access to the blood and produce their primary deleterious impression on 
some of the constituents of that fluid. Partly to these morbid changes in 
the blood, and partly to the direct presence and influence of the infection, 
is attributed the primary morbid impression upon the functions of the 
nervous system, and through it upon all the other functions of the body. 
Not a iew, however, place all the more important primary changes consti- 
tuting the essential pathology of fevers in the blood itself ; and thereby 
adopt doctrines as strictly humoral as were entertained, by any of the 
ancients. Whatever may be the opinions entertained, however, in regard 
to the primary changes or first links in the chain of morbid actions in the 
development of idiopathic fevers, there is a very general disposition, at 
the present time, to regard the pyrexia or increased heat as the one essen- 
tial pathological condition common to all fevers. So prominent, indeed, 
is the place assigned to increased heat as the essential morbid condition in 
fevers, by writers of the present day, that to it are attributed nearly all the 
molecular or structural changes that take place in the organized structures 
of the body ; and its control within proper limits is presented as the 
chief object of treatment. Indeed, the expressions used by many, both 
in speaking and writing, fairly convey the impression that increased heat 
and fever are convertible terms ; or in other words that fever is essentially 
increased heat. Yet, a moderate amount of careful observation at the 
bedside, is sufficient to demonstrate that in every case of general fever, 
there is a co-existence of many functional disturbances, of which calori- 
fication, or increased heat is only one; innervation another; circulation, 
secretion, nutrition, and tissue disintegration are others. And an ade- 
quate amount of impartial clinical observation shows, also, that there is no 
uniform order of sequence in these disturbances, but rather that they are 
developed coincidently from some cause capable of disturbing all simul- 
tanously, though not always in the same degree, nor in the same direc- 
tion. To call either increased heat or disturbed innervation fever, is 
simply to mistake a prominent symptom or effect of disease for the disease 
itself." 

To define fever as the " reaction " of living structures or vital forces 
against primary impressions of a depressing character, or as the " effort of 
nature" to throw off or expel some offending material, as has been done 
so long, is simply to use words and phrases that convey no definite patho- 
logical meaning, as I have already explained to you in the second lecture 
of the present course. If the complex and very important morbid condi- 
tion universally recognized as a fever, is not merely increased heat, nor 
the reaction, or "resilience" of the system from nervous depression, nor yet 

* See Flint's Practice of Medicine, 3d Edition, p. 808. 



56 GENERAL PATHOLOGY OF FEVERS. 

a mere alteration of the blood, the question recurs: what is it? Must we 
agree with Dr. Wood, that it is something we cannot fathom — something 
too remote in the intricate processes of the living system to be observed, 
analyzed, and understood by the human mind? I think not. On the con- 
trary, it has seemed to me that the obscurity resting upon this subject has 
depended entirely on the failure to recognize the existence of those gen- 
eral properties belonging to all living matter, which I endeavored to 
explain to you fully in the second lecture of the present course. While 
/'ever does not consist primarily in either an alteration in the blood, a de- 
pression or disturbance of the nervous functions, the circulatory, the secre- 
tory, the nutritive, or calorific processes, alone ; it does consist in the 
action of some cause capable of disturbing the general elementary prop- 
erties common to all the organized structures, which I have called suscep- 
tibility and vital afhnitv; and it is the active disturbance of these proper- 
ties that soon involves disturbance of all the functions and processes 
named; not in any fixed, consecutive order, but simultaneously, as from a 
common cause. The nervous structures have special well-defined func- 
tions, imparting sensibility, voluntary and organic; and directing muscular 
action, both voluntary and involuntary. 

By thus receiving and transmitting impressions and regulating muscu- 
lar action, they serve the purpose of placing one organ in relation with an- 
other ; they influence the caliber of all vessels containing muscular fibres 
in their coats, and thereby influence the quantity and motion of the blood 
in the vessels of each part ; by thus influencing the quantity and motion 
of the blood, they indirectly influence the activity of secretion and mole- 
cular motion, and consequently to a certain extent nutrition and disinte- 
gration ; and by influencing all these they carry an influence to a limited 
extent over calorification. It can thus be seen that morbid impressions 
made on the nervous system, may consecutively and indirectly involve all 
the functions and processes of the living system. But it is also true, that 
the derangements thus produced by primary impressions on the nerves, 
whether of a depressing or exciting character, differ widely from the phe- 
nomena of an idiopathic fever. If you study closely every recognized 
morbid state of the nervous system, from the highest state of nervous ex- 
citement to the lowest stage of nervous depression, you can find nothing 
either in the symptoms, progress or results, that bear even a moderate 
resemblance to the symptoms and progress of a general fever. On the 
other hand, it must be admitted that mere alterations in the blood alone 
cannot produce the phenomena of general fever. The blood may be, and 
doubtless generally is, the vehicle into which the morbific agents consti- 
tuting the efficient causes of fever, are received, and in which such agents 
are conveyed to every structure of the body. And it is the impression of 
these morbific agents, thus conveyed simultaneously to all parts of the 
organized structures, directly upon the properties common to ali, that 
produces, coincidently, general disturbance of all the functions and pro- 
cesses performed in the system. It is the action of some agent, conveyed 
in the blood, capable of producing an active disturbance of the elementary 
properties — susceptibility and vital affinity — by which the excitability and 
molecular changes in all the tissues are controlled, that constitutes true 
fever. It is this simultaneous disturbance of all the functions and pro- 
cesses, by active impressions on the properties common to all living struc- 
tures, that essentially distinguishes general fever from local diseases of an 
irritative or inflammatory character. 

While most of the general diatheses and constitutional diseases and ten- 
dencies result from causes acting with feeble intensity, but persistently 



GENERAL PATHOLOGY OF FEVERS. 



57 



upon the same general properties; the general fevers all result from cause? 
toting temporarily, but with greater intensity, and thereby producing 
acute general functional disturbance, instead of mere modifications of nu- 
trition and temperament. If it be true that fever consists essentially in an 
acute general disturbance of the functions and processes of the animal 
economy, from the impressions of some toxfemic agent acting upon the 
general elementary properties common to all living organized matter, as I 
have claimed, you can readily appreciate the truth of Dr. Copland's as- 
sertion that there is a "oneness" or unity in all fevers. Such oneness or 
common bond of union consists in the primary disturbance of the same 
gener.il properties, from the direct impression of any and all causes cap- 
able of inducing general fever. But while all the causes capable of pro- 
ducing fever act primarily upon the same general properties, thereby mak- 
ing a common point of departure in the establishment of pathological 
changes, yet each specific cause impresses these properties in a direction 
peculiar to itself; and hence leads to the development of symptoms and 
pathological changes equally peculiar, thereby explaining the diversities 
seen in the different forms of fever. For example, one cause or group of 
causes, may so act as to increase both the suscsjitibility and the vital 
affinity, thereby producing a fever of direct excitement, corresponding to 
the Synocha of the ancients, and the irritative, evanescent, or transitory 
fever of later writers. 

Another may so act as to depress both properties, and thereby lead to 
the phenomena characteristic of the typhoid and typhus family of levers. 

Another may produce such an impression as to increase or exalt the 
susceptibility, while it impairs the vital-affinity, thereby inducing fevers of 
high temporary excitement with impaired tonicity of tissue, represented 
by the family known as periodical fevers. Still another group of causes 
may act in such direction as to increase the excitability or susceotibility, 
while they pervert the vital affinity in a manner differing from simple in- 
crease or diminution, and by which specific molecular changes and combi- 
nations are effected, as seen in the group of specific eruptive fevers. These 
diversities in the primary pathological conditions resulting from the action 
of different causes on the same general properties, may be seen, perhaps 
more clearly, by the following tabular statement, which I place before you 
on the blackboard: 



ELEMENTARY 
PROPERTIES. 



IS p IS y y | B ^ i ™d.. 



Susceptibility 
Vital Affinity 



Susceptibility 
Vital Affinity 



Both diminished 



Increased 
Impaired 



( Fever of Pure Excitement. 

( Febeicula. 

f Fever tending directly to De- 
J bility or Functional Im- 
pairment. 
(_ Typhoid Group. 

f Fever of high temporary Ex- 
J citement, with impaired 

Tonicity, etc. 
I Periodical Group. 



f Fever of Excitement, with 
ci rrr , T -, specific local developments 

Susceptibility Increased I / -, formation of kr#ufc 

.. 1 ana loimauon 01 opecino 

I Eruptive Group. 



Vital Affinity Perverted 



Having thus stated as clearly as possible the first and essential link in 
the chain of mo:bid actions constituting the pathology of fevers, I Avill 



58 GENERAL PATHOLOGY OF FEVERS. 

next direct your attention to the more important subsequent changas, at 
least so far as they are common to this whole class of diseases. The first 
important effect resulting from a disturbance of the general elementary 
properties, is an alteration of the molecular movements in the various tis- 
sues, which necessarily involves coincident disturbance of the processes 
of nutrition, disintegration, secretion, calorification and innervation. 

The movement of atoms, cells, or molecules in all the tissues taking 
place under the guidance of these properties, and adjusted to certain nat- 
ural relations between the motion of the blood in the capillaries, the sen- 
sibility of the vaso-motor nerves, and the affinity of the structural ele- 
ments ; whatever alters the latter, must of necessity alter in a correspond- 
ing direction the movements themselves. 

And as the evolution of heat in the living body is the result of atomic 
changes in the tissues, it must increase or diminish, pari passu, with the 
increase, diminution, or perversion of such changes. The idea that car- 
bonaceous foods are used in the living system for the support of respira- 
tion and animal heat, as taught by the chemico-physiological schoo' of 
Liebig, is contrary to many well-known physiological and pathological 
facts, and was fully disproved by a series of experiments performed by 
myself in 1850, the results of which were presented to the American 
Medical Association in May, 1851, and published in the Chicago Medical 
Journal the following month.* 

You must remember, however, that the accumulation of heat, or the 
actual temperature of the living body, as indicated by the clinical ther- 
mometer, does not necessarily, or even generally, correspond with the 
rajridity of direct heat production, either in sickness or health. For while 
all those atomic or molecular changes taking place in the tissues by which 
the moving matter passes from a rarer to a denser condition, increases 
the sensible heat; those by which the matter passes from a denser to a 
rarer condition, absorb, or render sensible heat latent. 

It is plain, therefore, that the actual temperature of the body at any given 
time will depend as much upon the diminution of the latter processes, as 
upon an increase of the former. 

Among the most important of the latter processes are the eliminations 
from the lungs and skin. From the mucous membrane lining the whole 
extent of the respiratory passages and the cutaneous surface, water is con- 
stantly being converted into aqueous vapor, by which a large amount of 
sensible heat is rendered latent and the temperature of the body corres- 
pondingly reduced. As a general rule, during the active stage of all 
fevers, these extended surfaces are drier than natural, and it is highly prob- 
able that the accumulation of sensible heat is due more to the diminished 
exhalation of aqueous vapor than to any other one cause. From these re- 
marks you will readily perceive that while the evolvement of heat in the' 
living human body results directly from the molecular or tissue changes, its 
retention in a free state depends more upon the degree of activity in tha 
conversion of water into aqueous vapor in the processes of elimination 
from the cutaneous, pulmonary and intestinal surfaces. 

Therefore, while the increased heat in one case of fever may depend on 
an increased activity of molecular changes in the tissues; in another it may 
depend partly on increase of these changes, and partly on lessening of the 
exhalations of aqueous vapor; and in still another, the same elevation of 
temperature may be owing entirely to the diminished exhalations from the 

* The maintenance of a nearly uniform temperature throughout the whole forty days of recent 
fasting by Dr. Tanner, is also strong evidence that the production of heat in the system is not de- 
pendent on the ingestion of any particular kind of food. 



GENERAL PATHOLOGY OF FEVERS. 59 

free surfaces of the body, while the rapidity of the tissue changes may be 
only natural, or even less. I am aware that many neurological experiment- 
alists regard it as an established physiological law that the metamorphosis 
of tissues and the production of heat, are regulated by the nervous system.* 
But an attentive study of the results of experiments, in connection with 
abundant clinical observation, has satisfied me that the only influence ex- 
erted by the vaso-motor or trophic nerves over tissue changes and tempera- 
ture, results from their power to increase or diminish the contraction of the 
blood vessels, and thereby alter the quantity and motion of the blood in any 
given part. Yet a more or less profound disturbance of the functions of 
the nervous structures of the body is present in all fevers. The direction 
and intensity of such disturbance will vary, however, not in any strict con- 
sonance with the variations of febrile heat, but rather with the character 
and intensity of the exciting cause, and the previous predispositions of the 
individual patient. 

Another condition common to all general fevers, is a profound disturb- 
ance of those molecular changes which constitute secretion, and tissue 
change. But while such disturbance ahvays exists in a febrile condition, 
there is no uniformity in its direction or activity. x\s I have already told 
you, most of the writers on fevers at the present time regard the increase of 
heat in fevers as the direct result of increased tissue changes. If this 
were true, we ought to find a uniform ratio between the rapidity of such 
changes as shown by the quantity of the excreta, and the degree of 
fever heat. But the results of my own observations, as well as those of 
Parkes,Virchow, Wunderlech, Joseph Jones, and many others, show no 
such uniform relation. On the contrary, the quantity of the excreta pass- 
ing from the skin, lungs, kidneys, and bowels, whether considered as a 
whole, or from each source separately, varies much in the different varie- 
ties of fever, and in different cases of the same variety. And these vari- 
ations are found to have no uniform relation to the variations in the febrile 
heat.f 

Again, we find in the progress of all the varieties of idiopathic fever, 
decided changes in the quality and constituents of the blood. 

If you keep in mind the fact that the blood is the primary receptacle for 
all the products of tissue changes, as well as for the new material received 
through the organs of digestion and assimilation, you will see how readily 
the condition of the blood must be affected by whatever seriously disturbs 
the processes of either assimilation, nutrition, or disintegration. And, as I 
have already shown these processes to be profoundly altered by the action 
of all causes capable of inducing general fever, you would expect to find 
the blood more or less changed as a necessary coincident condition. But 
if it were possible for the processes just named to remain natural during 
the progress of a general fever, and the function of excretion through 
the skin, lungs, kidneys and bowels, by which the products of tissue- 
change and other materials are separated from the blood, was interfered 
with, speedy alterations in that fluid would necessarily result. Again, the 
specific poison that constitutes the direct exciting cause of the disease, 
may, on entering the blood, exert a morbid influence on the constituents 
of that fluid, as suggested by Murchison, Flint, and many other recent 
writers. 

It is probable that all the three modes by which the quality and quan- 
tity of the constituents of the blood are capable of being changed, co-ex- 

* See the recent very interesting researches of Dr. H. C. Wood, ,of Philadelphia, Published 
by the Smithsonian Institute. 

f See Aitken's Science and Practice of Medicine, p. 2G2, Vol. 1. 



60 GENERAL PATHOLOGY OF FEVERS. 

ist in most cases of general fever, but in very varying degrees of import- 
ance in different cases. For instance, in those constituting the group, 
which, in the preceding lecture I classed as continued fevers, we find an 
excess of most of the elements derived from tissue changes, with little de- 
ficiency of those of a nutritive and formative character, but a decided im- 
pairment of the quality or properties of both classes of constituents. The 
coagulability of the fibrin is impaired or entirely destroyed ; the red cor- 
puscles are darker color, and cease to attract each other in forming rou- 
leaux as in health ; the haematin escapes, tinging the serum and the 
fluids often found in the serous cavities, a redish color; and in typhus, as 
well as in the more malignant cases of other members of this group, there 
is an excess of ammonia, with an unusual tendency to putrifactive changes. 

On the other hand, in the members of the group classed as periodical, 
characterized by frequent critical or periodical evacuations, as in the 
copious sweats that terminate each paroxysm of an intermittent, there is 
seldom found any excess of the ordinary products of tissue changes, or 
much apparent impairment of the properties of either fibrin or red cor- 
puscles, but a marked diminution in the quantity, or relative proportion, 
of all the nutritive and formative constituents, more especially of the al- 
bumen and red corpuscles. The latter I have found in many cases re- 
duced much below one-half of their natural proportion. Frierich, J. For- 
syth Meigs, and others, have shown by numerous microscopic examina- 
tions, that the blood in this class of fevers generally contains a notable 
quantity of a black pigment, in the form of small, dark granules. The same 
material is also found in the structures of the lungs, spleen, and liver. It 
is highly probable that this pigment is developed in some way from the 
rapid disappearance of the red corpuscles. 

Finally, another important circumstance common to all the essential fe- 
vers, or acute general diseases, is their self-limited duration. This re- 
sults in part from the essential nature of the morbid conditions which con- 
stitute a general fever, and in part from the nature and special affinities 
of the specific causes that give rise to those morbid conditions. If I am 
correct in asserting that a direct disturbance of the elementary properties 
of the living structures, sufficiently acute to profoundly alter the general 
processes and functions of assimilation, nutrition, secretion, innervation, 
and calorification, constitutes the essential pathology of all general fevers, 
it must be evident to all of you, that such active universal disturbance 
cannot be maintained indefinitely. It must terminate within a limited 
period of time, or it will necessarily work such changes in the organized 
tissues, as well as in the blood, that the life of the patient must cease. A 
careful study of the natural progress and results of all the varieties of this 
great and important class of diseases, has shown that all the milder cases 
inherently tend to recovery within from one to six weeks, and th^ more 
severe to the destruction of life within a similar period unless modified by 
the interference of appropriate remedies. 

Having thus explained the nature of the morbid impressions and result- 
ing morbid actions which constitute the true pathology of idiopathic fevers, 
and the more important facts and conditions common to them all, I must 
next direct your attention to the special consideration of each group sep- 
arately. I shall therefore enter upon the consideration of the continued 
fevers at the beginning of the next lecture hour. 



CONTINUED FEVEES. 61 



LECTUEE VIII. 

Continued Fevers— Their General Characteristics— Individual Members of the Class— Divisible 
into Three Groups, with Distinct Etiological Characteristics— First Group, Simple Continued 
Irritative or Transient Fever, or FebricuL:. 

GENTLEMEN: — Having, in the preceding lecture, presented a brief 
review of the opinions that have been entertained in regard to the 
general pathology of fevers, and pointed out those changes and symptoms 
common to the whole class, I now invite your attention to that subdivision 
or group of acute general diseases called continued fevers. The members 
of this group, though presenting considerable variety in regard to their 
etiology, symptoms and results, still present a sufficient number of items 
common to the whole to justify the placing of them under one head. 
First, in all of them the febrile symptoms may be regarded as continuous 
from the beginning to the end of the disease — at least from the initial 
stage to the approach of convalescence. It is this continuity of the febrile 
svmptoms throughout the course of these diseases that has given to them 
the title of continued fevers. By continuity I do not mean evenness or 
uniformity in the symptoms, for in each member of the group the temper- 
ature and other active symptoms may vary much in intensity from day 
to day, or at different parts of the same day; but they do not wholly 
disappear and return again at such regular intervals as to constitute peri- 
odicity. Second, while, all the members of this group are self-limited in 
duration, in the same sense that I have denned the self-limitation of all 
acute general diseases — that is, they must terminate within a limited pe- 
riod of time, either in the convalescence or the death of the patient; yet no 
one of them presents such an approach to exactness in the duration, either of 
its successive stages, or of its whole course, as is seen in the fevers classed 
as eruptive. On the contrary, they vary much, both in the relative and 
absolute duration of their several stages, and of their entire course. For 
instance, the prodromic or forming stage, may vary in length from a few 
hours to one or two weeks. The active febrile stage may last only a day, 
or continue four weeks. The defervescence, or stage of decline, may be 
abrupt, and marked by critical evacuations, or gradual. These remarks are 
not only true when comparing one member of this group with another, but 
in relation to the different stages of the same variety of fever. If you 
take typhoid fever as the most important member of the group, you may 
find the forming stage varying, in different cases, from three days to two 
weeks; the active febrile stage, from two to four weeks; and the stage of 
defervescence, from three to seven days; making the whole duration of 
the disease in different cases from three to six weeks. This is in marked 
contrast with the more definite length of each stage of the eruptive fevers, 
and also with the limited duration and regularity of the return of the par- 
oxysms of the periodical or malarious group. Third, in the members of 
this class or group there is not that manifest tendency to eliminate the 
specific cause through one or more of the excretory organs, as seen in the 
copious sweats that end each distinct paroxysm of the periodical group; 
nor to fix it by some special affinity in a single structure, as' seen in the 
lodgment of the specific viruses or contagions in the skin and portions of 
the mucous membrane, in the members of the eruptive group. 



62 CONTIx\ T UED FEVERS. 

In consequence of this failure to effect an early separation of the special 
exciting- cause or fever poison, when such exists, and its consequent longer 
retention in the blood, together with the coincident accumulation of some 
of the products of disintegration or waste of tissues, the blood undergoes a 
more marked and uniform deterioration of the quality of its constituents 
than in either of the other groups of fever. 

The particular fevers which I shall include in the group called continued, 
are the following;: Simple Irritative or Accidental Fever, Influenza, Den- 
gue, Typhoid, Typhus, Relapsing, Plague, Yellow fever, Erysipelas, and 
Diphtheria. 

Causes. — While all these varieties of fever are properly grouped to- 
gether as acute general diseases of a continued type, they differ much in 
their causes, symptoms and results. 

The three first named appear to be caused principally by the influence 
of atmospheric conditions acting primarily on the cutaneous and pulmo- 
nary surfaces in such a way as to interfere with the proper eliminations, 
thereby causing the retention of effete material capable of disturbing the 
properties of the tissues and suddenly developing a fever of marked excite- 
ment but of brief duration. The atmospheric conditions alluded to may 
consist in sudden and extreme changes in the temperature and moisture, 
or in the quantity of active oxidizing agents, as ozone, hydrogen peroxide, 
etc., and do not include a specific contagion, infection or fever-poison. Be- 
ing thus produced mostly by alterations in, what I may term, the natural 
constituents and qualities of the atmosphere, these varieties of fever are lia- 
ble to attack large numbers of people almost simultaneously, and to extend 
rapidly over large districts of country. On the other hand, the typhoid, 
typhus, relapsing fever and plague, are supposed to originate from the ac- 
tion of specific poisons, developed either from the decomposition of animal 
matter, or from the excretions of those sick with the same disease. These 
specific poisons are, by some writers, styled idio -miasms /by others, infec- 
tions or contagions; and by others, simply fever-poisons. They are capable 
of suspension in air, water, milk, and probably in many other articles of 
food and drink ; and with these they may be introduced into the human 
system, either through the lungs or stomach, and possibly by cutaneous ab- 
sorption. Suspended in these various articles, they may be transported 
from place to place, and retain their activity, provided they are kept in 
confined limits, as in unventilated rooms, holds of ships, trunks, boxes of 
goods, or clothing, etc. 

But free exposure to unconfmed and pure air, either destroys or dilutes 
them to such a degree that they become harmless. 

Whether the infections which give rise to the typhoid, typhus, relapsing 
fever and plague, are so many specific agents existing in the form of bac- 
teria, micrococci, or other microscopic germs, the propagation of which is 
favored by the accumulation of animal excretions in a moist state; or 
whether they are inorganic gaseous products of the decomposition of such 
matters, is not satisfactorily determined. A majority of the writers and 
investigators of the present day favor the germ theory. Whatever may 
be the special form of these specific fever-poisons, however, investigations 
have fully established the important fact that they accumulate and mani- 
fest their activity in the production of fevers, in direct ratio to the accumu- 
lation of animal matter and excretions in poorly ventilated and over- 
crowded dwellings, narrow streets and alleys, cellars, cesspools, and the 
moist soil of yards and lots around dwellings, whether in the city or the 
country. 

Hence, the fevers they produce are found wherever the population by it s 



CONTINUED FEVERS. 63 

density or carelessness, causes the accumulation of excrementitious matters 
sufficient to contaminate either the air of dwelling houses, or the water 
furnished for domestic use, with little or no regard to latitude, longitude, 
elevation or geological formations. The facts I have just stated furnish 
the basis of a large part of the sanitary improvements of modern times. 
Practically, it matters but little whether we know the identity of any spe- 
cific fever-poison or not, provided we gain an accurate knowledge of the 
conditions governing its production and the laws of its diffusion ; for so 
far as such conditions are under human control, they enable us to limit its 
evolution and spread as effectually as could be done by an antidote to a 
known poisonous agent. Concerning the three remaining fevers in this group, 
namely, yellow fever, erysipelas, and diphtheria, each appears to depend on 
a causation peculiar to itself, which may be more appropriately considered 
in connection with the clinical history of each disease than at the present 
time. Like the influenza and dengue, they prevail chiefly in an epidemic 
form, attacking large numbers in a community within a limited time ; but 
more limited in their topographical range, and much more plainly depend- 
ent on the direct action of some specific infection. 

Definition of the words infection, contagion, and miasm. — As the words 
infection, specific infection, contagion or contagium, and miasm, will neces- 
sarily be frequently used when speaking of the causes of disease through- 
out the succeeding lectures of this course, it is necessary that I should ex- 
plain the meaning of each; or rather the sense in which I shall use them. 
It is the more necessary that I should do this, because some authors and 
teachers use them simply as synonyms, freely interchangeable; while others 
attach a definite meaning to each, and yet differ much in denning such mean- 
ing. By the word infection, I mean a substance or materies morbi developed 
from the deteriorative changes in animal matter and animal excretions out- 
side of the living body, which is both capable of perpetuating and propa- 
gating itself where the atmospheric impurities and other local conditions 
are favorable, and also of producing sickness when introduced into the 
living body, either by inhalation with the air, or imbibition with food and 
drink ; but is not itself re-produced, at least not in an active form, in the 
living bodies of those laboring under the disease it has induced. 

While the agents thus called infections may re-produce and perpetu- 
ate themselves in an atmosphere of the proper temperature and containing 
the necessary impurities, and thereby give rise to the prevalence of dis- 
eases of an epidemic character in localities to which they have been trans- 
ferred in connection with baggage, articles of merchandise, etc., they are 
wholly incapable of doing so in localities where such temperature and im- 
purities do not exist. By a specific infection, I mean one developed from 
some particular animal excretion or organic matter derived from patients 
laboring under some form of disease, and which is capable of producing the 
same disease in other parties with whom it may come in contact. For in- 
stance, many claim that there is in the discharges from the alimentary ca- 
nal of patients sick with typhoid fever, cholera, etc., some constituent, which 
though harmless at the time of being voided, is capable of development 
by exposure to the air into an active infection that may produce the same 
diseases in other parties if imbibed either with the air, water or food. You 
will thus perceive that an infection is a substance, or disease-producing 
agent, developed into activity outside of the human body and under cer- 
tain local conditions, by which it may so rapidly multiply or propagate 
itself as to infect the whole atmosphere of cities or districts of country, and 
attack such large numbers of people as to constitute an epidemic of 
greater or lesser severity. 



64 CONTINUED FEVERS. 

By contagion, or contagium, I mean a materies morbi, or specific poison 
developed in the body of the sick, which, when brought in contact with 
another unprotected person, will produce in such person the same disease, 
thereby communicating a particular form of disease from individual to 
individual without regard to local conditions of any kind. For instance, 
if you place a patient affected with small-pox or measles in contact with 
another unprotected individual, in any atmosphere, however pure and at 
whatever temperature, the person so exposed will imbibe the contagion, 
or virus, and suffer from the same disease, during the progress of which 
the morbid material will be reproduced in quantity sufficient to inoculate 
any number of others who may come within its influence. The various 
eontagiums developed in the bodies of those laboring under the acute 
general diseases to which they give rise, may escape with the cutaneous 
and pulmonary exhalations in sufficient quantity to impregnate the air 
immediately around the patient, and may communicate the same form of 
disease to those who may be brought in contact with such air; or they may 
be communicated by inoculation with the blood or with the virus gathered 
from sores on the body of the sick. The contagium of syphilis, and per- 
haps a few other diseases, does not appear sufficiently volatile to impreg- 
nate the atmosphere surrounding the patient, and consequently is commu- 
nicable only by inoculation or actual contact. All contagions, however, are 
capable of becoming attached to the clothing worn by the sick, and with 
such clothing may be transported in trunks, boxes, etc., to any other place, 
and retain sufficient activity to communicate disease to such parties as 
may receive them. In regard to portability or capability of being trans- 
ferred from place to place in confined air, eontagiums and infections are 
alike; but they differ entirely in their mode of propagation. The eonta- 
giums develop only in the bodies of those sick, and spread from individual 
to individual, w T hile the infections develop outside of the human body in 
air containing certain impurities and at favorable temperatures, and they 
spread disease to many simultaneously or in rapid succession through an 
infection or poisoning of the atmosphere without regard to personal con- 
tact of one individual with another. Small-pox, measles, and scarlet fever 
are good examples of diseases produced by eontagiums; and typhus, plague, 
yellow fever, and erysipelas, of those produced by infections. I shall use 
the word miasm to indicate any of the products derived from the decom- 
position of organic matter, w T hether animal or vegetable, and capable of 
diffusion in the atmosphere. Those derived from changes in animal mat- 
ter and animal excretions may be distinguished as idio-miasms, and those 
from vegetable matter as koino-miasms. Of course, most of the eontagiums 
and perhaps all of the infections would be included under the more gene- 
ral term miasm. 

FIRST GROUP OF CONTINUED FEVERS. 

Simple Continued or Irritative Fever. — Having given you these 
preliminary statements and definitions, I now invite your attention to a 
consideration of the most simple variety of acute general diseases, called 
simple fever, irritative fever, or febricula. 

History. — Cases of this variety of fever have occurred in all ages, in all 
climates, and among all classes of people. This is owing to the fact that 
it depends upon the action of no one special cause, but from any influence, 
mental or physical, that is capable of producing an abrupt and active dis- 
turbance of the properties and functions of the system. 

Before pathological anatomy had made sufficient advancement to afford 



SYMPTOMS AXD PROGNOSIS. 05 

a foundation for distinguishing one fever from another, all such distinc- 
tions were founded entirely on the symptoms and tendencies as observed 
at the bedside o( the sick. 

Those presenting the most active and quickly developed febrile phe- 
nomena were classed under the head of Synocha. Those presenting con- 
siderable activity, yet slower in development and of longer duration were 
classed under the word Synochus. And those of the lowest type tending 
in their progress to early and dangerous prostration, were classed as Ty- 
phus. Under this arrangement the febricula or ephemeral cases of fever 
were included with those called Synocha. But as pathological anatomy 
became more generally and minutely studied, it was made apparent that 
the more protracted cases under the head of Synocha, nearly all of those 
classed as Synochus, with a small number ranked as Typhus, constituted 
but one form of fever presenting different degrees of severity, but the same 
general course and attended by the same pathological lesions. Conse- 
quently they were placed together under the name of Typhoid fever ; 
while the remaining grave cases continued to be called Typhus. Many 
have carried this re-arrangement so far as to omit all recognition of sim- 
ple continued or irritative fever, classing all the cases under the heads of 
typhoid and typhus. Such is the case in the works of Bartlett, Ziemssen 
and Bartholow. In doing so, however, they ignore some of the plainest 
facts of clinical experience, and place in the same group cases essentially 
different in causation, symptoms and pathological results. That cases of 
weil marked general fever are frequently met with, which arise from var- 
ious accidental or non-specific causes, run a brief course, and almost always 
terminate in recovery without any special or characteristic structural 
changes, is acknowledged by a large majority of writers and practitioners 
both of this and past generations.* If we include these cases with those 
classed as typhoid, we not only violate the principle which constitutes the 
basis of all classification, by grouping under one head cases essentially 
dissimilar, but we vitiate all the statistics of typhoid fever proper, both in 
regard to the effects of remedial agents and the ratio of mortality. I shall 
therefore continue to maintain the distinctions here indicated, and give 
you a brief statement of the symptoms, causes, pathological changes, and 
treatment of simple fever. 

Symptoms and Progress. — This form of fever usually com- 
mences abruptly, without any marked forming or prodromic stage, 
and in most instances without a noticeable chill. In a small proportion of 
the cases, patients have complained of feelings of indisposition or lassi- 
tude one or two days ; but the attack is generally ushered in with pains in 
the head, back and limbs; flushing or redness of the face; increased heat 
and dryness of the skin; a thin white fur on the tongue; accelerated and 
full pulse; respirations more frequent; urine less in quantity and deeper 
color ; bowels inactive ; appetite impaired ; considerable thirst and gen- 
eral restlessness. The temperature of the body rises rapidly, generally 
reaching its climax in from six to twenty-four hours, at which time it will 
range between 40° and 42° C. (102° and 108° F.) 

The temperature thus reached, and the assemblage of symptoms enu- 
merated, may continue only a few hours, before they commence notably 
to abate coincident with the commencement of some critical evacuation 
occurring either spontaneously or induced by the action of remedies. In 
other cases they may continue, with but little change, from one to four or 
five days, when they decline rapidly, accompanied by some critical evacu- 

* Sec Aitken's Science and Practice of Medicine, Part I, pages 560-362. 

5 



66 SIMPLE CONTINUED FEVER. 



ations, and convalescence is established. As this grade of fever is one of 
pure excitement, caused by some agent or influence capable of exalting 
the properties of the tissues, it must terminate either in an early convales- 
cence, or in the establishment of some local inflammation, or in such decline 
in the activity of febrile excitement as to impart a more typhoid character 
to all the symptoms. It appears to be impossible, from the nature of the 
elements and processes involved, that a fever of direct excitement or ex- 
altation of the properties of living structures, such as I have just described, 
should continue beyond a very limited period of time without undergoing 
one of these three changes or destroying the life of the patient. In the 
great majority of cases, the rapid accumulation of the products of tissue 
changes in the blood caused by the general diminution of the secretory and 
eliminative functions, so far diminishes the stimulant influence of that 
fluid, within the first twenty-four hours, that the morbid excitability 
begins to decline, and soon reaches a point favorable for the resumption 
of natural molecular changes, when the skin, kidneys, and pulmonary sur- 
faces resume active eliminative work, and the fever spontaneously disap- 
pears. Such a result, as I have already stated, may occur at any time, 
from three hours to as many days; and is often hastened by the patient's 
taking freely of diluent drinks, and bathing the head, face, and hands in 
cool water. When this favorable change does not happen, by the third or 
fourth day, the lips become more dry; the whole countenance more dull; 
the pains in the head, back, and limbs less acute; the pulse softer but 
more frequent; the mind more dull, and sometimes wandering; the mouth 
more dry and tongue more thickly coated with a brownish strip along the 
middle line; the urine remains scanty; and the bowels inactive. Jn a 
word, such cases begin to show a tendency to a lower grade of excite- 
ment, and an approximation towards the typhoid aspect. Every day of 
further continuance makes this approximation more manifest; especially 
in hot climates, or in the summer and autumn of colder ones, until before 
the end of the second we )k the whole tongue and mouth become dry; the 
temperature from 40° to 41° C. (102° to 106° F.); skin dry; the counte- 
nance more dingy and dull; mind more wandering; and the abdomen 
moderately tympanitic, with intestinal discharges of a thin, brown or gray- 
ish color. The common expression of the attending physician is, that " the 
case commenced as a simple fever or bilious attack, but has run into a 
typhoid condition" In temperate climates nearly all of these cases con- 
valesce before the middle of the third week; but in warm climates they 
sometimes terminate fatally. In the cold season of the year some of the 
attacks of this variety of fever become protracted in duration, and more 
dangerous, by an early supervention of catarrhal inflammation in the mu- 
cous membrane of the bronchial tubes, not unfrequently extending into 
isolated lobules of the lungs.* 

Pathological Anatomy. — As this variety of fever rarely terminates 
fatally, the opportunities for postmortem examinations are still more rare. 
In the few instances in which such examinations have been made, the 
pathological lesions were simply such as had resulted from local compli- 
cations. 

Etiology. — As I have already remarked, simple irritative fever has no one 
specific cause; but may be produced by the action of any cause or combina- 
tion of causes that are capable of inducing, either directly or indirectly an 
active exaltation or increase of the elementary properties and functions 
of the system. Careful observation has shown that the most common 

* See Address of Dr. Wm Pepper, President of Section on Practical Med., etc. Transactions of the 
American Medical Association for 1881. 



TREATMENT. 67 

causes are exposure to extreme heat, or sudden and severe changes of tem- 
perature; violent mental emotions of an exciting character, such as 
sudden anger or great joy; and the use of irritating ingesta, as indi- 
gestible food and stimulating drinks. A large majority of the cases of 
this fever occur in childhood and youth, and are chiefly traceable to 
the two first named causes. Continuous exposure to high temperature, 
when not accompanied by a corresponding increase in the conversion 
of free into latent heat by active eliminations from the skin and air 
passages, causes the temperature of the system to rise rapidly with 
increase of susceptibility and derangement of molecular movements in 
the secreting organs and tissues generally, thereby establishing an active 
febrile excitement, or irritative grade of fever, with all its usual symptoms. 
Cases arising from this cause are common in India and other tropical 
countries, and often involve such sudden and extreme rise of temperature 
with so great an interference with the molecular changes, as to prove 
rapidly fatal. They are much more rare in the temperate and colder 
regions, but even here cases are met with every summer during the 
waves of high atmospheric temperature, and not unfrequently pass under 
the names of sun fever and partial sun-stroke. But in our climate expos- 
ure to sudden and extreme changes of temperature, by which the elimina- 
tions from the skin and respiratory surfaces are so violently interfered 
w r ith that waste material of irritative quality is caused to rapidly accumu- 
late in the blood and tissues, where it directly excites the properties of the 
whole to a febrile grade of activity, is, beyond doubt, the most common 
exciting cause of simple or evanescent fever. That sudden and severe 
mental emotions of an exciting character, are capable of occasionally 
producing so decided an influence over the vaso-motor nervous functions 
as to suddenly check secretory and eliminative actions, and quickly in- 
duce well marked febrile phenomena, has been acknowledged through all 
periods of medical history. 

Treatment. — Whatever may have been the cause or causes giving rise 
to an attack of this variety of fever, the sudden rise of temperature coin- 
cident with greatly retarded excretory actions and consequent rapid 
accumulation of effete matters in the blood and tissues, which uniformly 
characterize it, present two well defined indications for rational treatment. 
These are, to reduce the excess of heat, and restore the activity of the 
excretory and eliminative functions. If these are successfully accom- 
plished early in the progress of any given case, full convalescence follows 
and no further treatment is needed. But in all the more protracted 
cases, there is a third indication, namely, to detect and efficiently coun- 
teract, by proper means, the beginning of any local inflammatory complica- 
tions. It is true that many of the attacks of simple fever terminate spon- 
taneonsly without the aid of the physician, within twenty-four hours, by 
simple rest, abstinence from food, bathing the head, face and arms with 
water, and the free use of diluent drinks. It is also true, that nearly all 
of the attacks would terminate favorably by a continuance of these same 
simple remedial influences for several days in succession. It is neither a 
legitimate nor logical conclusion, however, that because a disease is nat- 
urally limited in duration, and very generally tends to recovery without 
the interference of art, therefore, it is not necessary or proper for the phy- 
sician to interpose any treatment. On the contrary, it is clearly his duty to 
study carefully the processes by which nature effects a recovery of the patient 
and by the judicious and timely use of such remedies as will aid the same 
processes, not only hasten their work, but render it more certain and com- 
plete. To reduce the temperature of the body and the rapidity of the 
circulation down to the standard favorable for the resumption of active 



6S SIMPLE CONTINUED FEVEK. 

secretory and eliminative action, is the first step in the treatment. This is 
most readily and fully accomplished by frequent sponging of the whole 
surface with water as cold as is comfortable to the patient, and the internal 
administration of some cardiac or vascular sedative in doses sufficient to re- 
duce the force and frequency of the pulse more nearly to the natural standard. 
And if the sedative can be combined with some agents that allay rest- 
lessness and promote the eliminations from the skin and kidneys, and the 
patient is allowed the free use of cold water for drink, the rational indica- 
tions for treatment will be more fully met. For the purposes just mentioned 
[ have long used, with much satisfaction, the following combination: 
Ijc, Spiritus JEtheris Nitrosi, 50. c.c. — 3-iss. 

Tincturae Opii Camphoratis, 50. c.c. — |iss. 

Tincturae Veratri Viridis, o.c. c. — 3i. 

If you give to an adult four cubic centimeters or an ordinary tea spoon- 
ful in a tablespoonful or two of water, every two or three hours, according 
to the intensity of the fever, you will soon reduce the pulse to 70 or 75 
per minute, and bring on general perspiration, with some nausea. As soon 
as these effects are obtained, you must increase the interval between the 
doses, aiming to so graduate the effect as to hold the febrile action in check 
without carrying the sedative effect of the veratrum viride far enough to 
induce vomiting. 

Similar effects may be obtained by the efficient administration of aconite 
and gelseminum, and still more speedily by one or two doses ofpropvlamin 
sufficient to produce its free sialagogue and diaphoretic effect. In most cases 
no further treatment is necessary; the fever being once subdued and gen- 
eral secretory action restored, does not return. If the bowels, however, 
should be slow to move, evacuations may be hastened by a mild saline lax- 
ative. In cases where the fever has already continued twenty-four hours 
or more before the physician is called, and he finds the tongue much coated 
and the urinary secretion very scanty and high colored, much advantage 
may be gained by giving at the beginning of the treatment, in addition to 
the frequent spongings and arterial sedatives, one or two powders, each 
containing nitrate of potass, pulverized, five decigrams (gr. viii,) and calo- 
mel two decigrams (gr. iii.) rubbed together with a little sugar, and follow- 
ing in about four hours with a saline laxative sufficient to cause two or 
three intestinal evacuations. But the free use of emetics and cathartics at the 
commencement of attacks of irritative fever, before the temperature and 
high excitability of the tissues have been modified by the antipyretic use 
of water externally, aided by internal sedatives, as was customar}^ in former 
times, and is still recommended by some writers, is productive of more 
harm than good. The active determination they cause towards the gastric 
and intestinal mucous membranes often aids directly the establishment of- 
such a degree of local hyperesthesia as to both protract the duration of 
the fever, and increase its disposition to assume a typhoid character. My 
own observations have served to sustain the remark of Dr. Eberle in his 
work on practical medicine, which was a text book nearly half a century 
since, to the effect that he had never seen a case of simple continued fever 
in which an active emetic had been administered at the beginning of the 
attack, that reached final convalescence in less than three weeks. When 
local inflammatory complications exist in connection with this variety of 
fever, they must be treated on the same principle, and with the same reme- 
dies as would be required for the same grade of inflammation unassociated 
with a general fever. As the duration of cases of simple fever under ju- 
dicious management is generally very brief, the period of convalescence is 
also short, and attended by no special sequalaa. 



INFLUENZA AND DENGUE. 69 



LECTURE IX. 

Influenza— Its History, Symptoms, Causes, Prognosis and Treatment ; Dengue— Its History, Sj-mp- 
toms, Causes, Prognosis and Treatment. 

GENTLEMEN : The disease to which I shall call your attention first 
at this hour, is known under various names, as Influenza, Epidemic Bron- 
chitis, Epidemic Catarrh, LaGrippe, etc. The first, which is of Italian origin, 
I shall adopt as the most familiar to the profession. Influenza is a general fe- 
brile disease usually abrupt in its access, irritative in its grade of activity, of 
brief duration, but pretty uniformly accompanied by a grade of inflamma- 
tory action in the mucous membrane of the respiratory passages. 

History. — This disease has frequently prevailed in an epidemic form, 
and was pretty accurately described as early as the tenth century. Itspe- 
riods of epidemic prevalence have been remarkable for the rapidity of 
their progress, the wide extent of territory over which they pass, and the 
great numbers of people attacked. It has several times prevailed over 
nearly all the countries of Europe and Asia.* Perhaps the most noted peri- 
ods of its prevalence in this country were in 1761-2, 1775, 1807, 1831-3, 1847, 
1857 and 1872-4, — at which times it not only extended its prevalence overall 
the inhabited parts of this continent, but also over the greater part of Europe 
and Asia. The disease has generally been represented as originating in 
the northern part of Asia, and spreading from thence to the southeast over 
Europe and crossing the Atlantic to America. For instance, the great 
epidemic of 1761-2, is by most writers described as having originated in 
Chinese Tartary, from whence it spread over Russia, Germany, Holland 
and the British Islands ; and from the latter southward through France and 
Italy, to the Mediterranean, and westward across the Atlantic to America, 
which it is represented to have reached in October, 1762. 

On the other hand, however, Noah Webster, in his *' Brief History of 
Epidemic and Pestilential Diseases," published in London, 1800, describes 
the disease as extensively prevalent in America during the year 1761, and 
as passing from thence to Europe in 1762. The same writer claims that 
the disease passed from America to Europe in three other important epi- 
demics, i. e. 1698, 1757, 1781. The truth is, gentlemen, that a careful ex- 
amination of the best accounts of a large number of the important epi- 
demics of influenza, shows no uniformity whatever, either as to their place 
of origin, direction and the extent of their spread, or the rate of their pro- 
gress. The writers of each country that it invades, attribute its origin to some 
neighboring country ; while in different epidemics the spread has been in 
opposite directions. 

As I have just stated, that of 1762 first appeared at the northeast of 
Europe in February, London in April, and France in July; while that of 
1775 was first noticed in Italy, from whence it appeared to extend directly 
northward until it reached the north of Europe; and in the epidemic of 1847, 
it was prevailing simultaneously at Copenhagen, London and Marsailles. 
Indeed one writer who claimed to have examined the histories of all the 
noted epidemics of this disease for the three last centuries, came to the 
conclusion that the general course of spread was from the west to the east. 

* See Aitken's Science and Practice of Medicine, p. 706. 



70 INFLUENZA. 

The rapidity of its progress, or more properly, the length of time be- 
tween its appearance in one section of a country and another more or iess 
distant, is very variable. Thus the epidemic of 1762, had invaded nearly the 
whole of Europe during the first six months of the year; that of 1830-1- 
2 occupied more than eight months to extend from St. Petersburg to the 
south line of Germany; while that of 18-47 made its appearance in all parti 
of Europe within the short period of six weeks. The great epidemics of 
influenza to which 1 have thus far alluded, have occurred at periods of time 
varying from ten to fifty years; and have differed much, both in regard to 
the number of persons attacked and the severity of the disease. They 
have also occurred at all seasons of the year, and in all parts of the globe, 
not omitting the islands of the ocean. 

Si/mpto?ns. — As a general rule the attacks of influenza are sudden and 
without any forming or premonitory stage. The first noticeable feelings 
of illness are generally coldness, varying in degree from simple rigors or 
sensations of coldness in the back and limbs to a severe chill of half an 
hour in duration. This is accompanied by feelings of depression, shrink- 
ing and paleness of the surface, variableness of respiration and pulse, with 
dull pains in the head, back and limbs. This stage soon gives place to a 
steady and continuous grade of fever, characterized by heat and dryness 
of the skin, some redness of the face, congestion of the vessels of the con- 
junctiva, moderate fullness and frequency of the pulse, some thirst, with 
little or no relish for food, bowels inactive, urine diminished in quantity but 
deeper color, and severe pains in the head, especially through the frontal, 
temporal, and orbital regions, with some pain in the back and limbs. Gen- 
erally, within twenty-four hours from the beginning of the attack, the mu- 
cous membrane of the respiratory passages becomes severely congested, 
causing coryza, copious thin secretion from the nostrils, some soreness in 
the fauces, hoarseness, harsh cough, with a sense of tightness or constric- 
tion in the chest, and great sense of weakness. You have thus all the 
symptoms of a moderate grade of general irritative fever associated with 
acute catarrhal inflammation of the membrane lining the nostrils, fauces, 
pharynx, trachea, larger bronchial tubes, and sometimes the frontal and 
maxillary sinuses. The symptoms usually reach the climax of severity dur- 
ing the seeond day, and continue with but little change in their general 
character from three to seven days, terminating in either a profuse sweat 
or a temporary diarrhoea, most frequently the former. With these appar- 
ently critical evacuations the general febrile symptoms disappear, and the 
local catarrhal irritations soon follow, leaving the patient fully convales- 
cent, but weak. Although the pyrexia in this disease is continuous, it 
varies much in intensity in different epidemics, and in different cases oc- 
curing in the same epidemic. The temperature ranges from 38° to 40° 0- 
(101° to 104° F.), and may vary from one to two degrees during the same 
twenty-four hours ; the exacerbation generally taking place in the even- 
ing. 

The discharge that takes place from the nostrils and from the membrane 
lining the fauces and bronchial tubes;, is, in the early stage, thin and gen- 
erally copious, but after the third day it becomes more opaque, less in 
quantity, and more easily dislodged. In the most severe class of cases the 
catarrhal inflammation extends to the membranes lining the frontal sinuses 
and antrums, not only adding much to the pains in the head and face, but 
sometimes causing, in the advanced stage, sudden and copious discharges 
of a yellowish serum, or muco-purulent fluid through the nostrils. The 
symptoms and progress of the disease, as I have detailed them to you, cor- 
respond with my personal observations during the severe epidemics of 



PROGNOSIS. 71 

1847, 1857 and 1872-3. Sporadic cases of influenza, presenting all the 
more characteristic symptoms that I have enumerated, are met with during 
the cold seasons of every year. They are most frequently seen during the 
first one or two mild days following a protracted period of severe cold. 

Prognosis. — The disease varies much in its severity in different epidem- 
ics, and in different cases occurring in the same epidemic. As a general 
rule, its prevalence is attended by only a small ratio of mortality. Most of 
the fatal cases occur in infancy or early childhood, and in old age ; and are 
largely due to the supervention of pneumonia, pleurisy, or capillary bron- 
chitis. And yet most writers claim that its prevalence increases the fatal- 
ity of consumption and other diseases accompanied by exhaustion, to such 
an extent, that the years of its epidemic prevalence are accompanied by a 
general ratio of mortality above the average. 

Pathological Anatomy. — Though the disease generally completes its 
course in from three to seven days, and ends in the recovery of the pa- 
tient, yet, in all the more severe epidemics a sufficient number of fatal 
cases have occurred to afford ample opportunities for post mortem exam- 
inations. The only important pathological changes noticed have been 
those of intense injection of the vessels of the mucous membrane lining 
the nostrils, pharynx, trachea, and larger bronchial tubes, causing redness 
and tumefaction of the membrane as in other cases of inflammation. So 
far the pathological changes belong to the disease and correspond with the 
severe catarrhal symptoms which constitute a part of the clinical history 
of each case. But most of the post mortems have also proved the exist- 
ence of pneumonic congestion and hepatization, and a few have revealed 
app2arances of active inflammation in the mucous membrane of the ilium 
and colon. These, however, are properly regarded as complications, very 
liable to occur in patients at either extreme of life — infancy or old age. 

Etiology. — The causes of influenza have not been reliably ascertained. 
The suddenness with which the disease is developed in an epidemic form, 
the great extent of territory over which it prevails, and the large number 
of persons simultaneously attacked, render it highly probable that its effi- 
cient cause or causes exist in the atmosphere. It is not a contagion devel- 
oped in the bodies of the sick; and there is no evidence that it is ever 
communicated from one individual to another. At an early period, Dr. 
J. K. Mitchell, of Philadelphia, suggested that it originated from minute 
cryptogamic bodies diffused in the air. In 1868, Dr. J. H. Salsbury, of 
Cleveland, published a paper claiming the discovery of a species of infu- 
sorium in the nasal discharges of a considerable number of cases of this 
disease, and which he regarded as the exciting or essential cause. Other 
microscopists, however, have not confirmed the correctness of his observ- 
ations. 

Schonbein, after discovering the existence of ozone in the atmosphere, 
and testitig its irritating effects on the mucous membrane of the air pas- 
sages, claimed with much confidence that epidemics of influenza were 
caused by an excess of atmospheric ozone. Nearly all the older writers 
attributed the disease to sudden and violent changes in the temperature, 
moisture and electric conditions of the atmosphere. On the other hand, in 
nearly all the more recent medical works, it is merely suggested that the 
theory of organic germs will most easily explain the phenomena presented 
by the history and symptoms of the disease, accompanied, however, by the 
frank confession that there are not a sufficient number of well established 
facts to justify an inference as to the efficient cause or causes of the dis- 
ease. I am not able to see how the theory of organic germs affords any 
more rational explanation of the origin and prevalence of the disease than 
any of the other hypotheses. 



72 INFLUENZA. 

It must indeed be, not only a remarkably accommodating, but really 
ubiquitous kind of organic germ that could in one epidemic propagate and 
diffuse itself over the whole of Europe, from the Mediterranean Sea to the 
north of Russia in six weeks; or over our own country from the Atlantic 
border to the Rocky Mountains, and from the St. Lawrence to the Gulf of 
Mexico in the same length of time ; and in another be six weeks in ex- 
tending from London to Edinburgh, six months in extending from Moscow 
to Vienna, and two years in reaching over both Europe and America. Or 
that could propagate itself and manifest its ravages almost simultaneously 
in all the latitudes or varieties of climate, soil and meteorological condi- 
tions between the equator and the poles. All we know of organic germs 
would tend to place them in the same relations as living bodies of larger 
size, which we well know are propagated and spread, only under certain 
pretty uniform conditions, and in accordance with fixed laws. 

From many years of observation, coupled with the well established fact 
that cases of sporadic influenza, presenting almost every symptom of the 
cases of epidemic disease, occur every year during the first forty-eight 
hours of warm atmosphere following a protracted period of intense cold, I 
am strongly inclined to the opinion that the efficient causes of influenza 
consist in such sudden and extreme atmospheric changes as are capable of 
producing correspondingly severe disturbances of the elementary proper- 
ties and molecular movements of living structures. I am the more inclined 
to this view from the additional fact, that the epidemic influenza sometimes 
attacks the horses, dogs, and other domestic animals, as severely and ex- 
tensively, as it does the human species. This was true of the remarkable 
epidemic that occurred in our country in the autumn of 1872. But this, 
like many other questions in etiology, will not be settled satisfactorily, un- 
til continuous and reliable records concerning all appreciable atmospheric 
conditions are kept, on a uniform plan, in many places, through a series 
of thirty or forty years, thereby furnishing all the data for comparing sev- 
eral epidemic seasons with the non-epidemic ones that precede and follow, 
in a sufficient variety of places to avoid mere coincidences. Here, gentle- 
men, is legitimate and very important work for medical society organiza- 
tions, that you will do well to remember after you have entered upon the 
active duties of your profession. 

Diagnosis. — This form of general acute disease is readily distinguished 
from all the other members of the class, by the suddenness of its access, 
its moderate and brief period of pyrexia, and the pretty uniform associa- 
tion of these, with the marked and severe catarrhal or inflammatory symp- 
toms manifested in the air passages. 

Treatment. — As nothing is positively known concerning the efficient 
cause or causes of the disease under consideration, our indications for 
treatment must be founded solely upon the actual pathological conditions 
presented by the patient at the time he comes under the care of the phy- 
sician, and the known tendencies of the disease. "When the physician 
arrives at the bedside of the patient, the initial chilliness has ceased, and 
he finds a moderate general fever, accompanied by diminished eliminations 
from the skin and kidneys, severe headache, and an actively congested 
condition of the membrane lining the nostrils, trachea and bronchial tubes, 
clearly indicating the need of such remedial measures as will lessen the 
pyrexia, relieve the pains, actively promote all the important excretory 
functions, and diminish the congestion of the mucous membrane of the 
respiratory passages. While these four objects or indications for imme- 
diate treatment are plainly presented bv the existing pathological condi- 
tions of the patient, you must remember the known tendency of the 



TREATMENT. 73 

disc se t) undue debility, or impairment of the nervous and muscular 
functions, and the frequent supervention of capillary bronchitis, lobular 
pneumonia and pleurisy, as important complications. The former should 
caution us against resorting* to measures for subduing- the pyrexia, of too 
actively sedative or depletive character, and the latter should keep us 
alert or watchful for the earliest symptoms that may indicate their exist- 
ence, that prompt measures may be adopted for their relief. If you thus 
comprehend definitely the special objects to be accomplished by thera- 
peutic agencies, you will readily select from the ample stores of the mate- 
ria medica a variety of agents more or less accurately adapted to accom- 
plish your purposes. In my own practice I have found the following 
outline of treatment more satisfactory in its results than any other. When 
called during the first or second day to cases of ordinary severity, I have 
generally ordered from four to six powders, composed of Dover's 
powder and nitrate of potassa, each five decigrams (gr. viii), an'd calomel 
one decigram (gr. iss ), one to be taken every four hours. Also the fol- 
lowing: 

^ Potassii Bromidi 20 gm. 3v 

Svrupi Scillae Compositi 4.5 c. c. ffiss 

Syrupi Ipecacuanhas 15 c. c. fjss 

Tincturae Opii Camphoratis, GO c. c. f|ii 

Mix, and give four cubic centimetres, or one ordinary teaspoonful, 
mixed with a tablespoonful of water half way between the powders. If 
the attack is severe, the pulse active and moderately firm under pressure, 
and the temperature under the tongue 39° (102° to 103° F.) or higher. I 
add to the formulae just given from four to six cubic centimetres (3i to 3iss) of 
the tincture of veratrum viride, and bathe the head, face and hands, and 
sometimes the whole cutaneous surface, frequently with slightly warm 
water. The continuance of these remedial measures for twenty-four 
hours, usually relieves the severe cephalalgia and restlessness, reduces the 
temperature, and develops a pretty free action of the skin and kidneys, 
with less cough and tightness in the chest. I now omit the further use of 
the powders, and follow them by a laxative sufficient to procure from one 
to three intestinal evacuations. The liquid mixture, however, may be 
continued in such doses as the stomach will bear without nausea, so long 
as the cough and catarrhal symptoms continue troublesome to the patient. 
After the bowels have been moved, I have not generally found it neces- 
sary to give, in addition to the anodyne and expectorant mixture just 
named, anything more than from two to three decigrams (gr. iii to v) of 
sulphate of quinia each morning and evening, and a fair amount of plain 
food. Patients have generally convalesced in from three to five days, and 
have rarely presented any of the more serious pulmonary complications. 
In some instances, however, mostly in persons beyond the middle period 
of life, there has appeared alter the second day such a degree of general 
weakness, that I have substituted in place of the mixture containing 
squills, ipecac, etc., a combination of syrup of senega, fluid extract of 
asclepias tuberosa, and camphorated tincture of opium, equal quantities of 
each, of which 4 cubic centimetres, or a teaspoonful was given every four 
hours, alternately, with one to two decigrams (gr. iss to iii) of sulphate 
of quinia in solution with aromatic sulphuric acid 0.6 cubic centimetres 
(10 minims). 

Many mild cases have been apparently cut short or aborted by giving at 
night a single powder containing from four to six decigrams (gr. vi to x) 
of Dover's powder, the same quantity of sulphate of quinia, and two to three 
decigrams (^r. iii to v) of calomel, following it by a laxative in the morning 



74 DENGUE. 

and 2 decigrams (gr. iii) of quinia two or three times a day for three or 
four subsequent days. 

It is probable that the same results would be obtained by giving one 
fair diaphoretic dose of pilocarpin in the evening and following it with 
moderate doses of quinia three times a day until the convalescence was 
well established. 

All patients should be required to take much rest, plain, but nutritious 
food, and good air, during the period of convalescence, and until their 
strength is well restored. Such cases as present important inflammatory 
complications in the pulmonary or other internal organs, must be treated 
on the same principles that govern the treatment of such inflammations 
under other circumstances. 

DENGUE, OR BREAK-BONE FEYER. 

History. — The acute general febrile disease described by most recent 
waiters, under the name of Dengue, has been recognized as a distinct 
variety of fever only in modern times. It is probable, however, that 
epidemics of this disease have occurred at longer or shorter intervals, 
from a remote period of human history. 

Some of them have been described under the names of miliary fever, 
break-bone fever, scarlatina rheumatica, dandy-fever, etc. The word 
Dengue, adopted by most recent writers, appears to have no special mean- 
ing; and is supposed to have been derived from the fanciful name 
"dandy" which had been popularly applied to the fever in some places on 
account of a peculiarly stiff manner exhibited by patients in attempting 
to walk. Uke the influenza which I have just been discussing, dengue 
seldom prevails except in an epidemic form, and then almost always in 
warm climates embraced in the tropical, and southern half of the temperate 
zone. It was described by Dr. Rush as prevailing in Philadelphia in 
1780, under the name of break-bone fever. It has frequently prevailed 
extensively throughout the East and West India Islands; in the southern 
part of Asia, Egypt, along the borders of the Mediterranean sea, and the 
southern half of our own country. The most noted epidemics of which 
we have full and accurate histories occurred in the Southern States in 
1828 and 1850. The first was fully described by that distinguished 
scholar and eminent medical teacher, Dr. S. H. Dickson, then of 
Charleston, S. C, and the second by Drs. Dickson and Wragg, of Charleston, 
Dr. H. F. Campbell, of Augusta, Ga., and Dr. E. D. Fenner, of New Orleans. 
You can find a pretty full and interesting abstract of the views of these 
respective waiters in the report on Practical Medicine to the American 
Medical Association in 1851, by Dr. Austin Flint, chairman of the com- 
mittee, and in the paper appended to that report.* 

Since the notable epidemic of 1850, the disease has repeatedly prevailed 
over more limited sections of country, chiefly in the West Indies and in 
the States bordering on the Atlantic and Gulf coasts, but sometimes as far 
north as the Ohio river. It not only prevails chiefly in warm climates, but 
also in the warm season of the year. It appears that its prevalence is fa- 
vored by the same circumstances that favor the development of malarious 
or periodical fevers ; and several writers have noted the fact that it has 
often, either immediately preceded or followed an epidemic of yellow fe- 
ver. 

When the disease prevails in any community it generally attacks large 

* See Transactions of the American Medical Association, Vol. 4, from p. 173 to 225, 1851. 



SYMPTOMS. 75 

numbers in proportion to the poru'ation, and so nearly simultaneously, that 
all must have been influenced by a common cause. The entire duration of 
the epidemic in Charleston, S. C. in August and September, 1850, was 
about six weeks. During the first four of these weeks, not less than seven- 
tenths of the entire population of the city were attacked, and Dr. Wragg 
estimates that more than 10,000 were sick at one time. This would be 
one-fourth of the whole population. It appears to attack indiscriminately 
all ages and both sexes. Perhaps the colored part of the population was 
less susceptible than the white. 

Symptoms and Progress. — In some cases the commencement of active 
febrile symptoms, is preceded for one or two days by some obscure feel- 
ings of indisposition, as general lassitude, dull pains in various parts of the 
body, sensitiveness to cold or heat, and depression of mind. 

But in the larger proportion of cases the attack is abrupt, and attended 
with chilliness, but not a full chill ; severe pains in the head, back and 
joints, especially those of the extremities ; intolerance of light and sound; 
skin hot and dry, face flushed, and tongue coated with a white fur. In a 
few hours the fever reaches its climax, when the face and head feel hot 
and excessively painful; the articular pains change rapidly from one joint to 
another, not omitting the smaller joints of the fingers and toes; the pulse firm 
and frequent; great restlessness, and sometimes severe vomiting of bilious 
matter, the bowels being generally inactive. This grade of active fever 
usually continues from two to four days, when a marked remission super- 
venes, during which all the more severe symptoms subside, leaving only 
slight acceleration of pulse, and some stiffness and soreness in the mus- 
cles of the lower extremities. 

This remission may last from twelve hours to two days, when nearly all 
the active febrile symptoms return, but with a little less severity than at 
first. The joints, however, become more red and swollen, and in almostall 
cases an eruption appears on the skin. It most frequently begins in the 
palms of the hands and soles of the feet, as an exanthematous eruption, 
and from those parts extends over the whole body, accompanied by much 
heat and itching, which added to the pains in the joints and muscular sore- 
ness, causes much restlessness and loss of sleep. The charactt r of the erup- 
tion varies much, in some cases resembling erythema, in others roseola, and 
in others lichen. It also varies much in amount, being in some cases only 
slight or altogether absent. It varies also in the time of its appearance, 
being sometimes manifested before the remission instead of coincident 
with the second accessor relapse, as some writers have styled it. The sec- 
ond paroxysm of fever usually continues three days, but in some cases 
ends in forty-eight hours; while in others it has been protracted to four or 
five days. It pretty uniformly ends with a critical evacuation. This gen- 
erally consists of a free diaphoresis, but sometimes takes the form of copi- 
ous renal or intestinal evacuations. You will see that the whole course of 
the disease from its access to its final termination occupies from five to 
nine days. It thus varies much in its duration and still more in the sever- 
ity of its symptoms ; many cases being so mild as not to require the at- 
tendance of a physician, while others are accompanied by the most intense 
suffering and followed by such a degree of weakness as to require several 
weeks to regain the usual health and strength. 

Prognosis. — This disease is rarely if ever fatal in adult life, and prob- 
ably not in children, unless it becomes complicated with convulsions or 
cholera morbus. It is remarkable for the rapidity of its spread; the large 
numbers attacked; the brief duration of its prevalence, and the almost 
entire absence of fatality. 



76 DENGUE. 

Erysipelas, purpura, and haemorrhages, have been observed as compli- 
cations in a few instances. Pregnant women attacked with the disease 
are very liable to miscarry. Relapses of the disease are not uncommon, 
and all severe cases are apt to be followed by a slow and tedious conva- 
lescence. 

Etiology. — Of the nature or identity of the cause or causes of dengue 
nothing is positively known. Its appearance usually in verv warm, drv 
seasons; the suddenness and rapidity with which it attacks a large part 
of the population of a city or district of country; and the brief period of 
its prevalence as an epidemic, are circumstances that could hardly co- 
exist in regard to any disease unless it was produced by some modifica- 
tions in the condition or composition of the atmosphere. Dr. E. D. Fen- 
ner, of New Orleans, who had good opportunities for studying the disease, 
evidently regarded it as only a modification of the ordinary malarious or 
periodical fevers, endemic throughout the Southern States. From the 
close similarity of circumstances relating to season of the year, geograph- 
ical limits of prevalence, rapid spread without personal contact, and double 
febrile course, separated by an intermission, more or less complete, we 
would be justified in assigning the disease a place intermediate between 
the malarious remittent and the yellow fever, and claiming as its cause some 
atmospheric agency similar in kind, but less virulent in its effects, than 
that which gives rise to yellow fever. 

Diagnosis. — As I have already intimated to you, Dr. E. D. Fenner 
regarded the disease called dengue as simply a modification of the ordinary 
endemic malarious fevers of warm climates. He adduces many and plau- 
sible reasons in favor of this view in the paper appended to the report of 
the committee on Practical Medicine, published in the Transactions of the 
American Medical Association for 1851, to which I have before alluded. 
If we consider, however, only its clinical history or symptoms and prog- 
ress, we should distinguish it from the intermittent and remittent types of 
fever, by the less marked chill at the access; by the continuance of the 
febrile exacerbation for two or three days instead of a daily intermission 
or remission; by the one long intermission and a second exacerbation of 
equal length with the first, accompanied by its swollen joints and cutaneous 
eruptions. From relapsing fever, which in some respects it strongly 
resembles, it is distinguished by the pain and swelling of the joints; the 
peculiar stiffness and soreness of the muscles; the eruptions on the surface; 
the shorter course of the fever; and the simultaneousness of its attacks on 
large numbers in a given population. The same symptoms and facts in 
its history, together with its almost uniform tendency to recovery, equally 
distinguish it from the epidemic form of yellow fever. 

Treatment. — The epidemics of this disease, that occurred from 1824 to 
1828, and from 1847 to 1850, developed so suddenly, and the fever and 
pains were so intense, that most of the earlier cases were treated with the 
active depletive and evacuant measures then so generally adopted in the 
treatment of all acute diseases. Blood-letting, emetics, cathartics, ano- 
dynes, calomel, and quinine, were all freely used, and each had their zeal- 
ous advocates, until it came to be fully understood that the disease, when 
left entirely to itself, almost uniformly terminated in full convalescence in 
from five to nine days. 

Since the general recognition of this important fact, the treatment pur- 
sued by far the larger number of American practitioners is very largely 
expectant, consisting in rest, light food, anodynes to allay pain and rest- 
lessness, diaphoretics to favor critical evacuations; and during convales- 
cence mild tonics and more nourishment. From the well-known efficacy 



15 gms. 


3iv. 


10 " 


3iis3. 


30 c. c. 


f?i. 


75 " 


ffiiss. 


45 « 


ffiss. 



TYPHOID FEVER. 77 

of salicylic acid in relieving rheumatic pains when associated with active 
pyrexia or high temperature of the body, especially when used conjointly 
with soda and diaphoretics, I should expect much benefit from its use in 
the active stage of the more severe cases of dengue. In such cases I 
would give three decigrams (gr. v ) of calomel, to be followed in five or 
six hours by a saline laxative, and the following formula: 

fy Acidi Salic vlici 

Sodii Bicarbonatis 
Glycerinse 

Tincturae Phytolacca^ 
Tincturae Opii Camphoratis, 

Mix, and give four cubic centimetres, or an ordinal teaspoonful every 
two, three or four hours, mixed with a little additional water when taken. 
This should be discontinued as soon as the active febrile symptoms, 
together with the severe pains and restlessness, cease. During the inter- 
mission between the first and second exacerbations of fever, and also 
during the final convalescence, the patient should avoid active physical and 
mental exercise, live on plain but nutritious food, and take from one to two 
decigrams (gr. ii to iii) of sulphate quinias three times a day. Of course, 
the doses of medicines I have mentioned are such as are proper for adult 
patients. For children the quantity must be lessened in proportion to 
their age. This, gentleman, completes the brief account I have deemed 
desirable to give concerning a group of general fevers characterized by 
active exaltation of the properties and general processes taking place in 
the human system, but brief in duration, tending very uniformly to recov- 
ery, and depending for their production mostly upon atmospheric causes 
that are also transient or incapable of continuous propagation. 



LECTURE X. 

Typhoid Fever— History, Causes, Symptoms, Diagnosis, Prognosis, Special Pathology, Pathologi- 
cal Anatomy and Treatment. 

GENTLEMEN: I must now call your attention to one of the most im- 
portant of all the acute general diseases. It is most important, from 
the wide extent of its prevalence, being liable to occur wherever human 
beings aggregate together in civilized and stationary communities, from 
its protracted duration, and from the high ratio of mortality that results 
from it. 

Typhoid fever has been recognized and described under various names, 
from the remotest periods of medical history. Until the days of M. Louis, 
of Paris, it had not been separated from the typhus fever, but had, with 
the latter, been described under the names of synochus, typhus mitior, 
and abdominal typhus. 

In later times it has been called typhoid fever, enteric fever, dothin en- 
teritis, common continued fever, pythogenic fever, and sometimes autum- 
nal bilious fever. In Germany and some other parts of Europe it is still 



78 TYPHOID FEVER. 

frequently called abdominal typhus, but in this country it is very gener- 
ally designated as typhoid or enteric fever. The latter name was applied 
to the disease by Dr. George B. Wood, but is objectionable, as implying a 
dependence of the fever on the intestinal lesions, and I shall adopt the 
fo.mer as the one most generally familiar to the profession in this countrv, 
and least likely to suggest erroneous pathological ideas. As I have al- 
ready intimated, the prevalence of typhoid fever is not limited to any 
soils, climates, topographical conditions, seasons of the year or classes of 
people. It occasionally attacks a sufficient number of people in a given 
community in a particular season to be called an epidemic, but its preva- 
lence is generally strictly endemic and continuous to a greater or less ex- 
tent throughout the year. 

I do not mean by these general expressions that this variety of fever 
prevails equally at all seasons of the year, or to the same extent in all 
localities. On the contrary, while in any given community cases of the 
disease may be met with every month of the year, yet as a general rule, 
it is much more prevalent during the last half of summer, autumn and 
winter than in the remaining seasons. And in relation to localities, it 
prevails more in cities than rural districts; and much more in districts 
and countries long peopled than in those recently settled by civilized 
man. The latter remark is more particularly applicable to such newly 
settled countries as present a soil and climate favorable for the develop- 
ment of the group of fevers styled periodical or malarious. Suah was 
the condition of a large part of our own country. 

The whole of this great interior valley, extending from Lake Superior 
to the Gulf of Mexico, the territory bordering on the gulf from the Rio 
Grande river to Key West, together with the Atlantic and Paoific slopes, 
presented at the time of their settlement by civilized races of men, a rich- 
ness of alluvial or tertiary deposits, containing decomposable vegetable 
matter in such quantity that malarial or periodical fevers took the prece- 
dence of all other endemic febrile affections, and typhoid fever was hardly 
recognized as having an existence during the first two generations. But 
as the settlements grew older, the population more dense, and the vege- 
table matter in the soil § lessened by cultivation, cases of typhoid fever 
began to attract attention, and from year to year became relatively more 
prevalent, until they have become familiar in every part of the country.* 

Etiology. — Perhaps there is no topic embraced in the domain of med- 
ical literature concerning which we have on record a greater diversity of 
opinions, or more directly contradictory statements by authors apparently 
equally entitled to our confidence, than concerning the efficient cause or 
causes of typhoid fever. Some few claim with much positiveness that the 
disease spreads by contagion emanating from the body of the sick, suffi- 
cient to infect the surrounding atmosphere. A much greater number 
deny th : s, and assert that the disease is never communicable directly from 
one individual to another by personal contagion. Until a comparatively 
recent period much the larger number of writers and eminent observers 
simply claimed that the efficient cause of typhoid fever was a poison, or 
class of poisons, produced by accumulations of animal matter or excre- 
tions, either in the confined air of dwellings and other buildings, or in 
moist soils, and capable of impregnating both air and water. The sup- 
posed poison or poisons thus engendered were called idio-miasms, to dis- 

* For a more detailed account of the development and progress of typhoid and tynTws fevers, the 
student can consult the second volume of Dr. D.miel Drake's work on the Principal Diseases of 
the Interior Valley of North America, from page 361 to 440. 



ETIOLOGY. 79 

tinguish them from the poisonous products of vegetable decomposition 
called koino-miasms, or more commonly, malaria. But since the applica- 
tion of the microscope to medical investigations, and the discovery of va- 
rious disease-producing germs, it has been assumed by nearly all our 
recent writers that the essential cause of typhoid fever is an organic germ 
of specific character, propagated chiefly, if not exclusively, from the intes- 
tinal evacuations of those sick with the disease. It is not claimed that 
such intestinal evacuations are capable of producing the disease when 
freshly voided, or of infecting the atmosphere around the patient so as to 
endanger nurses or friends in attendance on the sick; but that they con- 
tain immature germs, capable, under given circumstances, of further devel- 
opment, when they become capable of inducing the disease in others by 
impregnating either the air of dwellings, or the drinking water, or even 
milk from dairies. 

And we are assured by these authors that the disease never originates 
in any house or locality until these specific germs have been introduced 
from some previous case or cases. 

They contend that the poison never originates de novo, from any 
amount or kind of decomposing animal excrements unless the specific 
typhoid germ be present.* 

It is my duty, however, to caution you against receiving such positive 
assertions with entire confidence; and for the simple reason that an im- 
partial examination of all the more carefully observed and recorded facts, 
do not afford sufficient positive evidence of their correctness. Indeed, 
gentlemen, we have no direct or positive evidence that this much talked 
of " typhoid germ" has any existence except in the human imagination; 
for no one has yet succeeded in isolating, and satisfactorily identifying it, 
either with microscope or chemical apparatus. I do not claim that such 
actual identification is necessary before we are justified in admitting the 
existence of a poison or germ of some kind. For when certain effects are 
found uniformly to follow the coincidence of certain circumstances or con- 
ditions, we may logically infer that such circumstances or conditions give 
rise 1o the alleged effects, either directly by their own action, or indirectly 
by the evolution of some agent of peculiar or specific qualities. To make 
such inference legitimate, however, the supposed conditions must always 
be found either coincident with, or directly antecedent to, the alleged 
effects. Such coincidence between the local or recognizable conditions 
and the prevalence of certain diseases, such as intermittent, remittent and 
yellow fevers, has been traced with a reasonable degree of uniformity; 
and we may feel fully convinced that the coincident circumstances ac- 
tually evolve, or give origin to, the efficient cause of these fevers. We 
may go so far as to give this cause a name, calling it a miasm, or malaria, 
and study the laws that appear to govern its diffnsion. 

But typhoid fever has not been found to originate with uniformity from 
the juxtaposition of any special conditions of the air or earth or seasons. 
On the contrary, cases of the disease are met with, as I have already 
stated, at all seasons of the year, in all climatic zones, and among all 
varieties of people. And it is this very great diversity of the conditions 
under which typhoid fever has been observed, that renders it so difficult to 
trace it to any one specific germ as its essential cause. It is true, that 
many cases have been traced directly to the influence of foul air from 
cesspools, sewers and waste-pipes ; and others to water from wells, cis- 
terns and reservoirs, which had been contaminated by excretions. But in 

' * See A Treatise on the Practice"of Medicine, by Roberts Bartholow, M. D., etc., p. 689 ; also Lie 
oe.raeister, in Ziemssen's Cyclopaedia 



80 TYPHOID FEVER. 

only a few of these had it been positively ascertained that the dejections 
from typhoid fever patients had constituted any part of the contaminating 
material. One of the cases that has been regarded as affording the 
strongest proof of the propagation of the disease from germs in the evacu- 
ations of a person affected by the fever, was reported by Dr. Austin Flint, 
first in the American Journal of Medical Sciences in 1845, subsequently 
in his interesting volume of "Clinical Reports on Continued Ferer" in 
1852, and still later in the sc-vjral editions of his valuable work on the 
Practice of Medicine.* This case occurred in 1843, in a small village 
called North Boston, in the western part of New York State. A traveler 
from some one of the New England States, was taken sick on his journey 
westward, and on arriving at the tavern in this little village he was unable 
to go further, and after remaining a few days he died. The history of the 
case obtained by the physicians who saw it, rendered it reasonably certain 
that it was one of typhoid fever. Previous to the arrival of the stranger, 
this variety of fever had never been recognized in the neighborhood. 

In twenty-three days after the arrival of the stranger, members of the 
family of the tavern-keeper became sick with the same disease. Cases 
soon followed in the other families living in close proximity to the tavern, 
and in one month forty-three cases had occurred, constituting about one- 
half of the entire population of the village, and ten of those attacked died. 
The only family in this little community that entirely escaped the disease 
was one the members of which had no communication with the tavern or its 
inmates on account of personal enmity. The history of this little isolated 
outbreak of typhoid fever, so directly following the introduction of the 
disease by the stranger from New England, was first published by the 
distinguished author I have named, as furnishing positive proof of the 
contagiousness of the disease, he then supposing that it had spread by 
personal communication from one individual to another. Subsequent 
investigations, however, pretty clearly showed that all who had been 
attacked had been drinking water from the well belonging to the tavern, 
and that the privy, also used in common, was in close proximity to the 
well. The addition of these facts led to the supposition that the intestinal 
evacuations of the sick stranger, containing the typhoid germs, were 
thrown into the privy, from whence, after due development, they perco- 
lated into the well and contaminated the drinking water for the neighbor- 
hood. As this prevalence of typhoid fever in North Boston in 1843, is 
acknowledged to be one affording the strongest proof of the propagation 
of the disease by means of germs originating in the evacuations of typhoid 
fever patients, please note carefully the essential facts accompanying it. 
They are, first, the arrival of a stranger, sick with the fever, in a small 
settlement previously entirely exempt from the disease. Second, twenty- 
three days later the disease attacked members of the family in the house 
where the stranger had been entertained, and soon spread to all the fami- 
lies in the immediate vicinity, except one. Third, there was a icell and a 
privy in close proximity to each other, which were used in common by all 
the families in which the disease made its appearance. Fourth, it is sup- 
posed that the evacuations of the sick stranger were thrown into the privy. 
Fifth, all the families using water from the well near the privy had more 
or less of the fever, while the only family among them that did not use the 
water from that well escaped. 

These are the essential coincident facts. The inferences which have 
been drawn from them are that the evacuations from the sick stranger, 

*See a Treatise on the Principles and Practice of Medicine, etc. By Austin Flint M. D., etc. 
Fifth Edition, p. 962. 



ETIOLOGY. 81 

containing fever germs, were thrown into the privy; that the germs there 
finding a favorable medium, developed to the stage of activity, and then 
percolated into the well in sufficient quantity to contaminate the water 
and communicate the disease to those using it. You will see that the 
only part of these inferences which are actually justified by the facts, are 
the deposit of the stranger's evacuations in the privy and the subsequent 
sickness of those who used water from the well near by it. All that is 
said about germs is mere assumption, there having been no investigation 
made for their discovery, and of course none discovered either in the 
evacuations of the sick stranger or in the water of the well. So far as 
the ascertained facts show, the coming and death of the stranger may 
have been a mere coincidence, without having had any influence whatever 
in producing the subsequent outbreak of fever in the place. It would be 
just as legitimate and more nearly in consonance with other well-known 
facts, to suppose that the contents of the privy had been accumulating 
for two, three or more years, and each year percolating into and saturat- 
ing more and more the surrounding soil, until in this particular season 
the percolations had reached the adjacent well in sufficient quantity to 
contaminate the water, as to suppose the mere addition of a few evacua- 
tions from this unfortunate stranger had done all the mischief. The ques- 
tion Avhether the coming of the sick stranger was in this and other parallel 
cases a mere coincident, or a cause of the subsequent outbreak of fever, 
can be properly answered only by a close adherence to the acknowledged 
rules of evidence, or the well-known principles of inductive reasoning. 
If on examining the recorded histories of the various outbreaks of ty- 
phoid fever during the last half century, we should find that in eight 
out of every ten of such outbreaks one or more cases of the disease had 
been imported or received into each locality at a reasonable time prior to 
the occurrence of the first cases, we w r ould be justified in claiming that 
the efficient cause was in some way furnished by the cases arriving before 
the local development of the disease. 

On the other hand, if the recorded histories show no positive proof of 
the arrival of either patients or their excretions prior to the local devel- 
opment of the disease in nine out of every ten of the outbreaks on 
record, then certainly the proof of such preceding; importation in the 
tenth case can be properly regarded only as an accidental coincident. If 
we examine the collection of facts concerning the development and pro- 
gress of the typhoid outbreaks in this country, from the appearance of 
the "spotted fever" epidemic at Medfield, in the Connecticut River Val- 
ley in 1806, to 1850, contained in the second volume of the valuable work 
on the Principal Diseases of the Interior Valley of North America, by Dr. 
Daniel Drake, we shall find these occurring at different times, in every 
variety of locality, from the coast of New England to the Mississippi 
river, and from the Great Lakes to the gulf; in cities and sparsely popu- 
lated rural districts; among all classes of the people, and at all seasons 
of the year. 

And certainly not in more than one instance out of ten, is there any 
mention of evidence that the outbreaks were preceded by cases of the 
disease arriving from other localities. The brief histories of Dr. Drake 
are well supplemented by reports on the topography and epidemics of 
different States, contained in the annual volumes of transactions of the 
American Medical Association, from 1844 to 1870. 

Nearly all of these reports embrace accounts of the prevalence of 
typhoid fever in different parts of the country, mostly from intelligent 
members of the profession, who described what came directly under their 



82 TYPHOID FEVER. 

own observation ; and many of them in localities where the disease had 
never before prevailed, and where, from the sparseness of the population 
and comparative isolation, the questions of spontaneous origin or of 
importation of germs, could be investigated much more successfully than 
in large cities, or the older and more densely populated rural districts of 
European countries. In examining these, together with the reports on 
practical medicine and hygiene in the same volumes, we find but few in- 
stances in which the first development of the fever was traceable to any 
possible connection with previous cases, either in the same localitv or from 
other places. In a much larger number of instances, the question of 
sources from which some infection might have been received was not 
critically investigated, but none were detected or mentioned. While in a 
considerable number of instances, the origin of the disease spontaneously, 
from local causes free from the prior introduction of any cases or infectious 
germs from without, was so clearly established as to leave no reasonable 
doubt in the mind of any impartial observer.* 

In addition to the instances of spontaneous or local origin of this variety 
of fever given in the volumes to which we have alluded, a score of other 
instances could be collected from the pages of our periodical literature, 
where it occurred in jails, manufacturing establishments, boarding schools 
and private houses, under circumstances precluding all probability of its 
having had any connection with preceding cases or infection introduced 
from without. Two such instances have come under my own observation; 
and during an active practice of more than forty j^ears I have met with 
many single cases of well-marked typho'd fever: some in the country, oth- 
ers in the city, which passed through the regular ordinary course of the 
disease, each surrounded by family and friends; the urinary and fcecal 
discharges being promptly removed, and without disinfection thrown 
directly into the common privy-vault, without their having been either 
preceded or followed by any other cases on the same premises during a 
period of at least fifteen years. In many of these cases the patients had 
not been off from their own premises for many months, neither had any 
other case of that disease been on the premises for years previous. For 
thirty years past I have been an active member of the medical staff of the 
Mercy Hospital in this city. Apart of the medical wards have been under 
my care all that period of time, and typhoid fever has been one of the 
most common forms of disease under treatment. The patients laboring 
under that fever have been received into the same wards with other 
patients, and their evacuations disposed of in the same manner; yet, in not a 
single instance has the disease been communicated to the other patients. It 
is true that the wards have been kept clean and well ventilated, but no 
more so for typhoid fever patients than for all others. My experience in 
this respect is in direct accordance with that of many of the most experi- 
enced and careful observers in this country. f 

From the foregoing facts and references you will see that the positive 
assertions of Dr. Budd,J Dr. Liebermeister,|| and others, to the effect that 
typhoid fever never originated in any person or place without the pres- 

* See an account of the typhoid fever, etc., that prevailed on Cape Ann in 1833, by Joseph Rey- 
nolds, M. D., of Gloucester, Mass.,m Transactions of the Amer. Med. Association, Vol. Ill, p. 137, 1850. 
Also case related by Dr. Hartz, on p. 229. 

See Transactions of the same Association, Vol. V, pp. 308-334— Vol. VI, p. 356. Also Vol. 13, 1860, 
pp. 232-234. 

f Dr. George B. Wood, of Philadelphia, in the fifth edition of his Treatise on the Practice of Med- 
icine, page 351, uses the following emphatic language: "But against the opinion of its ordinary 
contagiousness is the fact, that it is constantly spriaging up in isolated cases, without any possible 
communication, and that, in such instances, it is very seldom, if ever, imparted to others." 

X see Flint's Practice, page 963. 

|| See Ziemssen's Cyclopaedia of Practice, Vol. I. from page 50 to 54 i elusive. 



ETIOLOGY. 83 

ence of the specific fever germs furnished by the excretions of those 
Buffering from the same general fever, are not sustained by the facts con- 
nected with the prevalence of that disease in this country. If you scan 
the statements of writers and observers more closely, you will find them 
all freely admitting that there is no evidence of infection or communica- 
tion of the disease from any kind of contact with the excretions of typhoid 
fever patients when freshly voided. It is only when such excretions have 
been kept in privy vaults, moist soils, or other places favorable for further 
decomposition, that the organic germs they are supposed to contain be- 
come developed into an active infection, capable of communicating the 
disease either by inhalation with the air, or by suspension in drinking 
water, etc. Direct microscopic examinations of the intestinal follicles, 
mesenteric glands and spleen, of typhoid fever cases, have been made by 
Von Recklinghausen, Klein, Fischel, Eberth, Sokoloff and Klebs, result- 
ing in the discovery of micrococci, bacilli, or bacteria, in about one-third of 
the number of cases examined; but nothing was discovered tending to 
show that these organic bodies had any agency in producing the fever from 
which the patients had died. There is, therefore, no proof of the exist- 
ence of a special fever germ, or specific organic poison, either in the fresh 
evacuations of typhoid fever patients, or in the diseased structures of those 
who have died from the gravity of the fever. Consequently the very 
general assumption that the essential cause of typhoid fever is a specific 
organic germ, capable of being propagated in the evacuations from those 
sick with the disease, must be regarded at present as a mere theoretical 
dogma. 

A careful adherence to well ascertained facts concerning the etiology 
of the fever under consideration will require us to accept the three follow- 
ing propositions : First, that cases of typhoid fever originate and 
multiply in dwellings or buildings of any kind, in which from either over- 
crowding the number of the occupants or the neglect of ventilation and 
cleanliness, the air, furniture and walls become strongly impregnated with 
the organic matter exhaled from the skin and lungs of the occupants.* 

So true is this that the annual returns of mortality statistics for every 
densely populated city in our country show the highest ratio of mortality 
from this disease, in the crowded tenement houses, manufacturing estab- 
lishments, and small dwellings of the poor. 

Second, that the more the soil of any given locality becomes impregna- 
ted with the intestinal and urinary excretions by the progressive increase 
of the density of the population, provided the two conditions of drainage 
and water supply remain the same, the more frequent and severe will be 
the cases of typhoid fever occurring among the inhabitants of such 
locality. 

This proposition has been so fully illustrated by the progress of settle- 
ment and increase of population in our country that its truth is established 
beyond controversy. In addition to this, the great number of outbreaks 
of the fever, which have been traced directly to the use of water impreg- 
nated with the percolations through the soil from privies, cesspools, house 
drains, etc., leave no room for doubt as to the influence of this agency in 
producing the disease. f 

* For a most interesting and valuable discussion of the amount of organic matter escaping from 
the lungs and skin in a given time, and the readiness with which the air of unventilated rooms may 
become contaminated from this source, see the Report on Public Hygiene by the late Dr. Joseph M. 
Smith, of New York, in the Transactions of the American Medical Association, Vol. Ill 
p. 223, 1850. 

t An important fact bearing upon this subject was stated by Dr. L. S. McMurtry, of Danville, 
Ken ucky, in an address delivered before the Kentucky State Medical Societv, in April, 1881, and 
published in the Medical News and Abstract fjr June, 1881. He says, "twenty years ago the dis- 



84 TYPHOID FEVER. 

Third, casos of genuine typhoid fever have occurred, and are still oc- 
curring occasionally, in almost every civilized community in persons who 
have had no traceable communication with previous cases of that disease, 
or with any of the recognized or even suspected sources of infection. I 
have met with many isolated cases 03curring in members of families liv- 
ing in houses in which a case of the disease had not been known to occur 
for ten years previously, neither did any Others follow for ten years after. 
Yet these individual cases Were surrounded and nursed by their respec- 
tive families, and their evacuations emptied into the ordinary water- 
closets belonging to the premises. Most of these cases appeared to 
originate from causes directly personal to the individuals affected, such as 
protracted mental depression and anxiety, excessive mental or physical 
work, and abrupt changes from active out-door occupations to passive in- 
door work. Assuming that typhoid fever is a specific disease, character- 
ized by a definite course, and accompanied by special or peculiar patho- 
logical and anatomical changes, many writers have claimed that it must 
have a single specific and essential cause, and consequently that all other 
causes apparently influencing the prevalence of the disease were only 
predisposing agencies. Probably no fact is better established than that 
the disease under consideration generally originates from the use of air or 
water impregnated with some one or more of the products derived from 
the decomposition of organic matter. It does not follow, however, that 
such product of organic changes must necessarily be formed outside of 
the human body. 

On the contrary, there are many facts that indicate the possibility of 
such modifications in the processes of disintegration of living structures as 
are capable of evolving septic or other poisonous material, which like all 
other products of tissue changes, are returned into the blood, where they 
are capable of acting on the general properties and inducing general 
febrile disturbances of the same character as when an organic poison is 
received from without. It is well known that some of the general acute 
diseases which ordinarily manifest no tendency to communicate from in- 
dividual to individual by personal contagion, in some rare instances have 
manifested this disposition in the most decisive manner. Several instances 
are on record of this kind in relation to typhoid fever; which can be ex- 
plained in no other way than by admitting that a disease ordinarily pro- 
duced by causes received from without may also originate from similar, if 
not identical, causes developed from perverted molecular changes within 
the living body. That protracted mental depression and anxiety, coupled 
with deficiency of sleep, is capable of modifying all the properties and 
molecular movements concerned in the processes of nutrition, disintegra- 
tion, and secretion must be admitted by all experienced observers. 

So, too, protracted and severe physical labor, by which the waste of tissues 
is made to exceed the supply or repair, may not on'y cause tissues to be- 
come so deficient in tissue material as to derange or pervert the move- 
ments of atoms, and consequently cause the formation of morbid products; 
but may also cause the ordinary jDroducts of waste to accumulate in the 
blood faster than the excretory organs can eliminate them, until such ac- 
cumulation becomes a cause of disturbance. Still more, may similar per- 

ease (typhoid fever) prevailed in epidemic form throuehout the villages and farming disMc's of 
this State almost every season with frightful severity. Now we rarely encounter typhoid fever ex- 
cept in isolated cases in which the disease was contracted elsewhere and Drought home in the 
formative stage." The reasons for this change he gives as follows : " Formerly wells with free sub- 
soil communication were the sources of drinking water ; now cisterns are almost universal sourc s 
of water supply in Kentucky. The geological formation is admirably adapted to the construction 
of cisterns, and the cemented cisterns of this State are practically sealed bottles into which the 
water pours through filters. " 



ETIOLOGY. 85 

versions of molecular movements in the processes of disintegration and 
elimination take place in those persons who in the early period of adult life 
change suddenly from active open air occupations in rural districts to the 
more confined indoor employments of our large cities. 

Such persons seldom get sick during the first few weeks after they change 
residence, but more particularly after from four to six months. The 
tendency of typhoid fever to attack persons who had resided in Paris less 
than one year, much more frequently than older residents, was noticed by 
M. Louis; and the same tendency has been observed in many other cities 
since. During the whole of my residence here I have not failed to observe 
that an undue proportion of those young persons of both sexes who 
change their residence from the country to the city in the winter or spring- 
have an attack of typhoid fever in the latter part of the following sum- 
mer or autumn, and those who make the change in the autumn are more 
liable to have the fever in the following spring or early summer. Among 
the predisposing causes of this variety of fever are generally enumerated 
age and season of the year. 

Statistics show that far the larger number of cases occur between the 
ages of 15 and 30 years, and in about an equal ratio in the sexes. The 
next period of life most amenable to attacks, is from 10 to 15, years, but 
no period of life is entirely exempt. 

In regard to the influence of seasons of the year, it must be remarked 
that particular epidemics and certain strictly local outbreaks in particu- 
lar houses or buildings, have occurred at all seasons of the year, yet it is cer- 
tain that the ordinary endemic prevalence of the disease is much greater 
in the autumnal months, than in any other. Generally in this city the 
attacks are observed to commence being more frequent the last half of 
August, and to reach the climax of their frequency in October; then gradu- 
ally declining through November and December, reaching nearly the 
minimum in January. In most years a slight increase takes place during 
the months of February and March, to be followed by a decline through 
April, and an actual minimum of prevalence through May and June. 
As a rule, a wet spring followed by a w «rm and dry summer is succeeded 
by an unusual pevalence of the disease in the autumn.* 

But I have already occupied your attention on the subject of the etiol- 
ogy of this fever longer than I had intended. If, however, I have suc- 
ceeded in impressing your minds with the importance of adhering to well- 
ascertained facts, and avoiding hasty and positive conclusions until all the 
facts have been ascertained, and each allowed its proper influence, the 
hour will have been spent profitably, both for yourselves, and the com- 
munities you are preparing to serve. 

* The present year, 1881, presents some peculiarities The winter was protracted later than 
usual with a great excess of snow. The melting of the snow not only caused a full saturation of 
the soil, but unusual floods over a large part of the country during March and April. This was 
foil wed by entire dryness during May and June; and the latter part of the last named month, a 
a severe grade of typhoid fever began to prevail in many parts of the city, and has continued with 
but little abatement to the present time time, July 20th, 1881. The health department of the city 
reports 24 deaths from typhoid fever, and 3 from typho-malarial fever, in June, which is a very 
much greater mortality than usually takes place in that month from the same diseases. In June 
of the preceding year, 1880, the number of deaths from the same fevers was only 9. 



86 TYPHOID FEVEK. 



LECTURE XL 

Typhoid Fever Continued— Symptoms, Diagnosis, Prognosis, Special Pathology, Pathological 
Anatomy, and Treatment. 

GENTLEMEN: An unmixed case of typhoid fever presents four stages 
or periods of progress requiring the attention of the physician, namely, 
the prodromic, or forming stage, the stage of active progress, the stage of 
defervescence or decline, and the period of convalescence. Those who 
believe in the origin of the disease exclusively from a specific fever poison, 
speak also of a period of incubation, the length of which, however, is made 
to vary from five or seven days to three or four weeks. It is hardly nec- 
essary, after the statements made in my previous lecture concerning tie 
causes of typhoid fever, that I should characterize the claim of a period of 
incubation as entirely hypothetical. 

The forming stage varies in different cases from five to fifteen days, the 
average being about one week. The second, or active stage, usually 
extends from two to three weeks, and the third, or declining stage, from 
five to nine days, making the average duration of the disease from the 
beginning of the symptoms to the establishment of convalescence about 
four weeks, or three weeks from the time the patient takes his bed. I 
have seen cases terminate in two weeks, and I have seen others continue 
six, seven, and some even eight weeks, before convalescence was fairly 
established. 

Symptoms. — The symptoms of the forming stage are chiefly feelings of 
languor, weariness, indisposition to mental or physical exercise, morbid 
sensations of heat and cold, indifference or loss of appetite, a mawkish or 
unpleasant taste in the mouth, especially in the morning after sleep, a 
numb and unsteady feeling in the head, especially on rising from the bed 
or chair, and in many instances a dull, steady pain in the head, back, and 
limbs. The expression of countenance is generally dull; the face some- 
times flushed and at others a leaden paleness; lips dryer than natural, and 
tongue usually coated with a dull or dirty white covering over the middle 
and posterior part, but sometimes remaining clean and moist through the 
whole of this stage. The skin is generally dryer than natural, and in- 
creased one or two degrees above the natural temperature; the urinary 
secretion slightly diminished, and bowels often failing to move each day, 
though easily moved by laxatives, and sometimes loose. The foregoing 
symptoms usually commence so gradually that the patient finds it difficult, 
often, to specify the first day he began to feel unwell. They increase, 
however, from day to day, especially the dullness and aching in the head; 
the weariness and unsteadiness of gait in attempting to exercise; and in 
from five to seven days, as a general rule, the patient feels obliged to re- 
main at rest or take to his bed, which marks the beginning of the second, 
or more active stage of the fever. It is rare that an unmixed case of ty- 
phoid fever is ushered in by an abrupt and well-marked chill, but it is 
very common during the latter part of the forming stage and the first 
two or three days of the active progress, for the patient to complain of 
coldness in undressing or in getting in or out of bed, and when questioned 
by the physician he often calls these momentary feelings, of coldness, 
chills. Many patients during the forming stage interpret their dullness 



SYMPTOMS. 87 

and feelings of indisposition as indications of " biliousness," and con- 
sequently take active physic to correct it, without consulting a physician. 
Instead of affording relief, however, such evacuants generally operate more 
freely than usual, and almost invariably hasten the time the patient is 
obliged to take his bed, and cause a continued looseness of the bowels 
much earlier than would otherwise have occurred. It is generally at the 
beginning of the second stage, when the patient is no longer able to be 
out of bed, that your aid as physicians w T ill be required. At that time, in 
addition to the symptoms already described, you will find the face more 
flushed; the lips more dry; the skin generally more dry and hot; more 
decided pains in the head, with the addition of dizziness on attempting to 
get up; some thirst, with more decided coating upon the tongue; repug- 
nance to food; the mind more dull, with inclination to drowsiness, yet 
somewhat restless; urine scanty, and bowels inactive, except in cases in 
which active physic had been given in the forming stage. In such you 
will often find slight tympanites, with gurgling on pressure, and from 
three to five or six intestinal evacuations in the twenty-four hours, even 
on the first days of the patient's confinement to bed. The pulse usually 
ranges between 85 and 100 per minute, and the temperature in the axilla 
about 38° C. (100.5° F.) in the morning, and 39° C. (102.5° F.) in the 
evening. If not materially modified by treatment, the assemblage of 
symptoms just enumerated will continue, steadily becoming more pro- 
nounced from day to day, until at the end of the first week after confine- 
ment to the bed, the temperature has advanced to 39°. 4 C (103°F.) in 
the morning, and to 39°. 9 C. or 40°.5 C. (101° F. or 105°F., in the even- 
ing. The patient will complain less of pains and restlessness, but appear 
more drowsy; the whole face more suffused with redness; less moisture 
in the mouth, and a strip over the middle of the tongue dry, and brownish 
color, while the tip and edges are red; mind often wandering, especially 
at night; pulse from 95 to 110, and more soft; respirations slightly in- 
creased in frequency, with harsh respiratory murmur, indicating dryness 
of the respiratory mucous membrane; more frequent intestinal discharges, 
generally reddish-brown and thin, though sometimes lighter, or ash-gray 
color; abdomen more convex and tympanitic; occasional epistaxes, or hem- 
orrhage from the nose; and in some cases, small, slightly oval red spots 
appear ahout this time on the chest and abdomen. The pyrexia, or essen- 
tial symptoms of the fever, are generally at the climax of intensity as the 
patient enters upon the second week of his confinement, and they con- 
tinue with but little variation through that week. The mental dullness 
and delirium may increase some; the whole surface of the tongue appear 
more dry and brown; some sordes may appear on the exposed part of the 
teeth and edges of the lips; the abdomen more decidedly tympanitic, and 
intestinal discharges more frequent and more thin and brown, containing 
small white flakes, and sometimes small masses of mucus with specks of 
blood adherent to them; more rose-colored spots appear and disappear 
over the chest and abdomen; more frequent epistaxes, and more dry 
bronchial rales. The morning temperature during the whole of this 
second week is generally between 39° and 40° C. (102.5° and 104° F.), 
and the afternoon and evening temperature from one to two degrees 
higher. 

The pulse may vary from 100 to 120 per minute, soft and weak; respi- 
rations from 18 to 22 per minute, with occasional cough, and imperfect 
inflation of the posterior, and lower part of the lungs. In cases tending 
towards a favorable termination, as the patient enters the third week of 
his confinement in bed, the disparity between the morning and evening, 



88 TYPHOID FEVER. 

temperature becomes greater, the former gradually declining to 37° or 
38° C. (99° or 100.5° F,), while the latter, though more unsteady, will still 
often reach 40.5° C. (105° F.) During this third week the flush leaves 
the face; the lips cease to gather scrdes; the mouth is less dry; the coat- 
ing on the tongue breaks up, and the edges become moist; some moist- 
ture appears on the skin, especially in the mornings; the bronchial rales 
are less dry; the abdomen is less tympanitic, and the intestinal discharges 
less frequent, and sometimes quite natural; delirium ceases, and the pe- 
riods of sleep are more pe feet. At the end of this week, or during the 
first half of the fourth, the temperature returns permanently to the natu- 
ral standard, the abdominal tympanites ceases, and convalescence is es- 
tablished. Such is the usual course of typhoid fever, when of average se- 
verity. Many cases run a milder course, and convalesce during the third 
week, while others are more severe, and do not reach a final convales- 
cence until the end of the fourth, or even during the fifth week after the 
patient takes to his bed. Bat in all the cases, the important symptoms 
are the same in kind, only differing much in the degree of severity. 
When the fever is of that grave character, which tends inherently 
towards a fatal result, the symptoms are much the same as I have just de- 
scribed, until about the end of the second week, at which time the patient 
becomes more constantly delirious; muscular movements more unsteady 
and sometimes tremulous; hearing more dull; temperature higher; pulse 
more frequent and feeble; respirations shorter and more frequent, with 
increase of bronchial rales, and commencing dullness on percussion over 
the posterior part of the chest; whole mouth dry, coat flakes off from the 
surface of the tongue, leaving it red, dry, and often fissured, with difficulty 
of protrusion; abdomen more decidedly tympanitic and intestinal dis- 
charges very thin, reddish brown, offensive, and often mixed with some 
blood, varying from three to six or eight in the twenty-four hours. 
Near the end of the third week, in the most severe, and during the 
fourth in those a little less so, the patient becomes entirely prostrate or 
exhausted. His countenance becomes pale and haggard: his chin be- 
gins to drop, leaving his mouth open, except when strongly aroused; deg- 
lutition difficult; his skin relaxed and moistened with a clammy sweat; 
extremities cool and of a leaden hue; pulse very frequent and feeble; 
sphincters relaxed, permitting both urine and feces to be discharged in- 
voluntarily; or the urine tc be retained until the bladder becomes over- 
distended, and then dribbles in the bed. When these signs of extreme 
exhaustion have supervened, the patient may linger one, two or three 
days, when death from asthenia supervenes; although, I have seen a few 
cases recover after all these more dangerous symptoms, had become well 
marked. 

In a very few of the more dangerous cases of typhoid fever, instead of 
somnolency, stupor, muttering delirium and coma, the patient manifests a 
morbid vigilance that admits of no sleep either night or day. The ex- 
pression of countenance is that of anxiety and apprehension; the pulse is 
small and very frequent, respirations hurried, the hands tremble, the skin 
is most of the time wet with perspiration, and yet the bodily temperature 
is high— from 40° to 41° C. (104.5° to 106° F.) These cases are always 
dangerous, as the nervous excitement and loss of sleep rapidly exhaust 
the strength of the patient. 

Throughout the first and second stages of typhoid fever of all grades of 
severity, there is considerable thirst, but either indifference, or positive 
repugnance to food, with more or less impairment of all the special senses. 
Hearing, especially is so impaired during the second and third weeks, that 



SYMPTOMS. 89 

in some cases the patients appear quite deaf. Vision is less affected, yet 
somewhat impaired, as are also the senses of smell, taste and touch. 
Such, gentlemen, are the chief symptoms presented during the progress 
of typical or uncomplicated cases of typhoid fever. If I should leave you, 
however, with the impression that the forming stage and first week of con- 
finement in all the cases of this disease corresponded in the symptoms 
with the detail just given, you would be very poorly prepared to appre- 
ciate the variations in different cases that you will certainly meet at the 
bedside of the sick. The untypical, or complicated cases of this fever 
may be arranged in three groups for convenience of description, namely, 
those cases presenting in the forming stage unusual symptoms of gastro- 
intestinal irritation; those accompanied by inflammatory action in the air- 
passages and pulmonary structures; and such as present at the beginning 
chills, with decided exacerbations of fever, so well marked as to resemble 
the early stage of a genuine remittent. Of those constituting the first 
group, I have seen some commence suddenly with all the phenomena of 
an ordinary attack of cholera morbus. After vomiting and purging 
severely from two to eight or ten hours, the former ceases, and the latter 
is reduced to simple diarrhceal discharges of a grayish, or turbid appear- 
ance, and a slow, febrile reaction takes place, causing the face to become 
flushed, the lips and mouth dry, the skin moderately hot, the mind and 
countenance dull, pulse small and increased in frequency, with considera- 
ble thirst and some drowsiness; and at the end of forty-eight hours, instead 
of convalescence, as is usually the case after a simple attack of ordinary 
cholera morbus, the patient presants all the phenomena belonging to the 
first part of the active stage of typhoid fever. I have seen a much larger 
number of cases commence with more or less active diarrhoea, without 
vomiting. 

At first the discharges will be simply thin fecal matter, of light yellow or 
grayish color, accompanied by little or no pain, and not more than three or 
four in the day. Each day, however, they become more watery and frequent, 
the patient feels dull and weak, his lips are dry, appetite poor, mind listless, 
but he often continues to attend to his usual work for several days, but 
is finally compelled to take his bed, at which time you will find him with 
ail the usual phenomena of the active stage of typhoid fever, except those 
pertaining to the alimentary canal will be unusually prominent. The 
cases belonging to this group, generally occur during the warmest part of 
summer, and appear to be modified in the forming stage by the causes 
that usually favor attacks of cholera morbus and ordinary summer diar- 
rhoea. On the other hand, cases belonging to the second group of untypi- 
cal attacks, are met with chiefly during the cold season of the year, more 
especially late in the autumn, and early in the spring, when there is much 
wet, with a predominance of cold. Every season some of these cases are 
met with, and are found by the physician, after the patient has taken to 
Ins bed, with the following history: For a period varying from three to 
six days, the patient had been unusually sensitive to impressions either of 
heat or cold, with many of the symptoms of catarrhal irritation of the air 
passages, such as dull pain through the temples, stuffing of the nostrils, 
slight soreness in the chest, with some cough, and some general soreness 
of the muscular structures on the back and extremities. The headache 
increased from day to day, the general feelings of lassitude and weari- 
ness became more marked, accompanied by more sense of heat and flush- 
ing of the face in the afternoon, and less feeling of ability to get up and 
go about in the morning. When the physician is called he finds the 
patient presenting the general symptoms I have mentioned, which he is 



90 TYPHOID FEVER. 

assured have all come from a " bad cold." On close examination, how- 
ever, he finds more dullness of expression, more general dryness of the 
skin, flush of the face, coating- of the tongue; a quicker, softer pulse; and 
higher temperature than usually accompanies an ordinary cold. Exam- 
ination of the chest and air passages shows evidence of a congested and 
rather dry condition of the nasal and bronchial mucous membrane, with 
occasional harsh cough. The urine is less than natural, and the bowels 
quiet unless they have been disturbed by physic, in which case they will 
have exhibited a tendency to looseness. 

You will perceive that these symptoms differ from those of an ordinary 
cold by presenting a steadily increasing temperature, and dryness of the 
air passages, at a time when the feverishness of a catarrhal attack should 
have disappeared, and the secretion from the mucous membrane be 
free and more or less opaque. Yet this fact is often overlooked, and the 
patient treated for a catarrhal attack or a sub-acute bronchitis, until an- 
other week has passed, when the typhoid symptoms become so prominent 
as to compel a recognition. This group of cases are not only complicated 
from the beginning by a low grade of inflammation in the respiratory 
mucous membranes, but a limited area of pneumonia is also very apt to 
supervene towards the end of the first or during the second week after the 
patient takes to his bed. You should remember this fact, and pay special 
attention to the physical signs elicited by an examination of the chest from 
day to day, for the pneumonic inflammation in many of these cases is not 
accompanied by the ordinary bloody expectoration, nor by so much pain 
as to attract the attention of patients. The thir 1 group of untypical cases, 
embracing those commencing with distinct chills and daily exacerbations 
of fever, are very numerous throughout the whole interior valley of this 
continent, from the great lakes to the Mexican Gulf, though becoming 
gradually less so from year to year. If you examine the facts collected 
by Dr. Daniel Drake, and those given in the various reports contained in 
the earlier volumes of Transactions of the American Medical Association, 
to which I referred in the lecture of yesterday, you will find much the larger 
number of the cases referred to described as commencing with a chill and 
followed, for the first two or three days, by well-marked exacerbations and 
remissions. 

The same phenomena accompanied the development of three out of 
every four cases of typhoid fever coming under my observation during the 
first ten years of my residence in this city, namely, from 1849 to I860. 
This fact led many of the older practitioners then living in the city, who 
had been accustomed to meet only genuine intermittents and remittents 
during an earlier period in the settlement of this part of the country, to 
persistently deny the existence of any cases of real t} r phoid fever here. 
They claimed that all such cases as I have included in this group, were 
true malarious or periodical fevers, with a tendency to "run into atypho d 
condition." And I have known many instances in which the attending 
physician repeated and increased his doses of quinine to " break up," or 
abort, the fever, until Liebermeister and all his followers were fairly out- 
done in the quantities of the anti-periodic (or, in more modern phrase, 
anti-pyretic,) given to the patient within a limited time. Nevertheless, 
the cases of fever continued their usual course, each day bringing the 
typhoid phenomena more prominent, until some of them proved iatal, and 
post mortem examinations showed all the characteristic intestinal and 
other lesions as perfect as in any cases ever described by M. Louis in 
Paris. Although this variety of cases is relatively much less frequent 
than thirty or iorty years since, they are still more or less prevalent every 



DIAGNOSIS. 91 

year, especially during the latter part of summer and autumn. And prac- 
titioners are still frequently deceived as to their nature when first called 
to attend them. It is not three weeks since I was called to see a case in 
consultation, in the southern part of the city, which at the time of my visit 
presented all the characteristics of a well-marked case of enteric typhoid 
fever about the middle of the second week of its progress. Yet the 
patient had sulfered from so decided a chill and exacerbation of fever, 
regularly each day for the first three days of sickness, that the attending 
physician felt compelled to regard it as a genuine malarious fever, and to 
commence the treatment in accordance with that supposition. To recog- 
nize the true character of these cases in the beginning, requires the clo.se 
and patient attention of the physician to the entire series of symptoms 
presented by the patient during the first forty-eight hours, -and the preced- 
ing forming stage. If such attention is given, it will be observed that 
though the initial chili is well marked, the temperature during the hot 
stage neither rises so rapidiy nor attains so high a figure on the thermom- 
eter, as in the hot stage of a remittent fever. It is not accompanied by 
the same degree of active thirst, restlessness, epigastric distress or vomit- 
ing, as at the climax of the paroxysm in the latter. Neither is the decline 
of the paroxysm so rapid, nor does the temperature of the patient return 
so near to the natural standard during the remission; and when there is a 
coat on the tongue, it is much thicker towards the back part and along the 
median line, than at the beginning of uncomplicated cases of periodical 
fever. If to these we add the greater dullness of expression, and less 
activity of thought and speech, we shall seldom fail to recognize the true 
typhoid character of these cases as soon as they come under our care. 
From the detailed description I have now given you of the different stages 
and varieties of typhoid fever, drawn directly from clinical observation at 
the bedside, you will not fail to recognize the fact that while cases present 
a wide difference in the degree of severity, and considerable diversity in 
the order of symptoms at the beginning, there is in all, both a universal dis- 
turbance of the general processes and functions of the body, and a recog- 
nizable sameness in the character and tendencies of such disturbance. 

Diagnosis. — There can be but little difficulty in arriving at a correct 
diagnosis in all typical or unmixed cases of typhoid fever. The long and 
gradually increasing feelings of indisposition before the patient is com- 
pelled to take his bed, and the gradual increase of temperature and oth t 
febrile symptoms through the first week of confinement, are so different 
from the abrupt beginning, and rapid rise of temperature, in the general fe- 
vers I have already described, that it w T ould hardly be possible to mistake 
one for the other. The same circumstances place it in still stronger contrast 
with the sudden access, high excitement, and rapid increase of temperature 
that characterize the first stage of fevers of the eruptive order; and in fact 
of all other acute general diseases except typhus. In the middle and lat- 
ter stages of the disease, the addition of the fully developed abdominal 
tympanites, gurgling on pressure, thin passages, and generally blunted 
sensibilities, render the contrast between it, and the other general fevers 
more striking even than in the first stage. The untypical cases are far 
more likely to be confounded with sub-acute bronchitis or pneumonitis; 
or similar grades of inflammation affecting the mucous membrane of the 
stomach and intestines, on the one hand; and with remittent fever on the 
other. But the more important symptoms on which we must rely for cor- 
rect diagnosis in these cases, were sufficiently indicated, when T was giv- 
ing the detail of symptoms, and need not be repeated here. There have 
been some cases of sub-acute meningitis in children, of cerebritis in adults, 



92 TYPHOID FEVER. 

and of acute granular or miliary tuberculosis, that were mistaken for ty- 
phoid fever. It was only yesterday that I saw a case of the latter variety, 
in the person of a young girl of 13 years, who was represented to have just 
passed through a period of three weeks confinement with what was sup- 
posed to be typhoid fever, but which was only the acute stage of tubercu- 
losis, as the whole upper part of the left lung is now giving all the physi- 
cal signs of purulent softening cr degeneration. Such cases can always 
be distinguished from the general fever by proper attention to the physi- 
cal signs of incipient tuberculosis, and the absence of the characteristic 
abdominal symptoms of the typhoid disease. The cases of sub-acute men- 
ingitis in children, always present conditions and changes in the pupils 
of the eyes, and nervous startings, very different from anything ac- 
companying the early stage of typhoid fever; and though the bowels are 
often loose in such cases, the character of the discharges are very change- 
able in color and quantity, and the abdomen lank, as if empty; a condi- 
tion 1 have never seen in the general typhoid disease. Some of the cases 
of cerebritis certainly present a train of symptoms closely resembling the 
fever under consideration. A case of this kind occurred in the practice 
of the late professor James McNaughton of Albany, in the person of a 
young man who died from what had been regarded as a protracted typhoid 
fever, but which the post mortem examination showed to have been a case 
of cerebritis, terminating in suppuration, and a well formed abscess in the 
central part of one of the cerebral hemispheres. The case was reported 
with great candor and minuteness, more than twenty years since, by the 
distinguished professor, I have just named. In all the cases of cerebritis 
that have come under my observation, the pain in the head has been more 
circumscribed, penetrating, and fixed to one place, and the patient has 
exhibited much greater aversion to free movements of the head, than in 
the general fever. Again, in the inflammation of the interior portions of 
the brain, the abdomen is not only empty and free from tympanites, but 
generally the bowels are very costive, thus presenting conditions just the 
reverse of those found in the general typhoid disease. 

Prognosis. — As I have already remarked, typhoid fever is limited in its 
duration, and its general tendency is to the recovery of the patient, es- 
pecially if placed under favorable hygienic regulations; and yet the ex- 
ceptions to this favorable tendency are sufficiently numerous to cause a 
high ratio of mortality. Its severity, and the consequent mortality, differs 
much in different seasons of its prevalence and at different periods of life. 

A large part of the statistics concerning the ratio of mortality have 
been collected from hospital records, and undoubtedly give a much higher 
ratio of deaths than takes place in private practice, under ordinary cir- 
cumstances. For instance, of over 18,000 cases, collected from the more 
important public hospitals of London, Glasgow, Paris and Strasbourg, by 
Dr. Murchison, over 18 per cent, or 1 in 5. 4 died. Of 1,420 cases men- 
tioned by Dr. Liebermeister, as treated in the hospital in Basle, an aver- 
age of 15 per cent, or 1 in 6.6, proved fatal. Dr. James Jackson, of 
Boston, in an interesting Report on Typhoid Fever, gives 303 cases 
treated in the Massachusetts General Hospital between the years 1828 
and 1835, of whom nearly 13 per cent, or 1 in 7 died. Of 73 cases given 
by Dr. Austin Flint, 24 per cent., or 1 in 4 terminated in death. Dr. 
George B. Wood states, that of the whole number treated by him in the 
Pennsylvania Hospital of Philadelphia from 1850 to 1854, less than 6 per 
cent., or 1 in 17 died. In the general hospitals of New York, such re- 
ports and statistics as have come under my observation, lead to the infer- 
ence that the average mortality resulting from typhoid fever cases is from 



PROGNOSIS. 93 

1 in 5 to 1 in 7, or from 15 to 20 per cent. During the thirty years from 
1850 to 1880, there have been treated in the wards of the Mercy Hospital, 
under my care, 520 cases of well marked typhoid fever, attended by a 
mortality of 1 in 16, or 6.2 per cent. During the first ten years men- 
tioned it was the only general hospital in this city, and as it then occupied, 
the greater part of the time, a building on Wabash Avenue, neither con- 
structed for, nor well adapted to, hospital purposes, its capacity was over- 
crowded by fever cases from the poorest classes of society. Still the 
highest ratio of mortality reached in any one year was 1 in 9, or 11 per 
cent. On the other hand, since the completion of the present ample 
hospital building in 18G9, several years have passed without a sing.e 
death from this disease in the wards under my care. There are two 
reasons why the Hospital Statistics show a high ratio of mortality from 
this disease. 

First, in this country especially, most of the patients admitted into the 
general hospitals are from the poorer classes of society, and have been 
living in the midst of bad sanitary conditions. 

Second, they are seldom brought to the hospital until they have reached 
the middle period in the progress of the disease, and sometimes so late as 
to admit of no treatment, being really in a moribund condition. I am 
aware that Dr. Budd has estimated that the average number of cases of 
typhoid fever occurring annually in Great Britain is 140,000, giving an 
annual mortality of 20,000, or 1 in 7. 

But from my own experience, and from what I have seen in the practice 
of others, I am satisfied that the ratio of mortality from typhoid fever 
under judicious management in private practice does not exceed one in 
from twenty to twenty-five, or from four to five per cent. The results are 
not only influenced by the different degrees of severity in different years, 
but also by the age of the patient. Far the greater number of cases occur 
between the ages of fifteen and thirty years, and the younger the patients 
the less is the ratio of mortality. But few cases occur after forty years 
of age, and a very high ratio of mortality results. Sex appears to exert 
but little influence over either the number attacked or the ratio of deaths. 
Those accustomed to the habitual or excessive use of alcoholic drinks 
yield a very high ratio of mortality.* 

If the temperature of the patient is maintained at or above 40.5° C. 
(105° F.) during the last half of the second week of confinement, it indi- 
cates a great degree of danger. If a similar high temperature is contin- 
ued both morning and evening during the third week of confinement, it is 
of still more unfavorable augury. But a high temperature found only at 
evening, while it recedes to 37.2° or 38.3° C. (99° or 101° F.) in the 
morning, either in the last part of the second, or during the third week, 
indicates a favorable result. My own clinical experience has led me to 
attach much less importance to the mere degree of temperature in typhoid 
fever, than is indicated in the works of most recent writers. I am certain 
that the condition of the kidneys, abdominal viscera, and lungs, afford a 
much more reliable guide for our prognosis than the temperature. If the 
kidneys fail to eliminate a full amount of urea and urates, either with or 
without the appearance of much albumen in the urine, even though the 
temperature of the body may be low, there is great danger attending the 
further progress of the case. The same is true if at any time after the 
middle of the second week the abdomen becomes largely distended w r ith 
tympanites; the intestinal discharges frequent and somewhat mixed with 

* Liebermeister states that of nineteen habitual drunkards having typhoid fever in the hos- 
pital at Basle, seven, or more than one-third, died. 



94 TYPHOID FEVER. 

blood, or unusually offensive; the spleen enlarged; with a soft, frequent 
and wavy pulse. 

If, instead of a simple admixture of blood with the intestinal discharges 
a genuine intestinal hemorrhage occurs, it indicates great danger of an 
early fatal result. And perforation of the intestine, which sometimes 
occurs in the advanced stages of the disease, or even during convalescence, 
is pretty uniformly followed speedily by general peritonitis, vomiting, 
collapse and death. The number of cases in which the hypostatic en- 
gorgement of the lower and posterior part of the lungs, coupled with 
i xtensive congestion of the capillary bronchial tubes, so far interferes 
with the oxygenation and decarbonization of the blood, that the latter 
fails to sustain the functions of the nervous centres; the patient becomes 
very drowsy; pulse and heart's action weak; cutaneous capillary circula- 
tion feeble; and the sphincters of rectum and bladder relaxed, allowing 
more or less involuntary discharges, and finally death, is greater than you 
would infer from most of the works on practice within your reach. The 
fatal result in many of these cases is attributed to cardiac weakness, and 
alcoholic remedies are resorted to with the idea of strengthening the 
heart; while in truth they only increase the deficiency of blood oxygena- 
tion, still further anaesthetize the nervous centers, and hasten the fatal 
result. 



LECTUKE XII. 

Typhoid Fever Continued— Its special Pathology, Pathological Anatomy, and Treatment. 

GENTLEMEN : After what I have stated to you in the lecture on the 
general pathology of all idiopathic fevers, it is not necessary that I dis- 
cuss at any considerable length the special pathology of any one member 
of the class. I then endeavored to trace the starting 1 point of all fevers to 
an active disturbance of those general properties of living organized mat- 
ter, that control atomic or molecular changes, and impart the capacity to 
receive organic impressions; in other words, to those general elementary 
properties that I have designated as susceptibility and vital affinity. The 
essential pathology of typhoid fever consists in such an impairment of these 
properties as to lessen the impressions of all the natural excitors of organic 
life, such as oxygen, light, heat, food, and mental activity, and to impair the 
regularity and activity of those atomic changes concerned in the processes 
of nutrition, disintegration, secretion, and elimination. In consequence 
of such impairment of the general properties, there necessarily follows 
corresponding impairment of nerve sensibility, of the generation of nerve 
force, and of the performance of all the primary functions of the body. 
The slow but steady increase of heat through the forming stage and first 
week of confinement, is evidently owing much more to a diminution of 
those processes by which free heat is rendered latent, than to any increase 
in the rapidity of tissue changes causing increased heat production. The 
impairment of the vital affinity on which the secreting structures depend for 
their ability to elect from the blood the elements necessary to form their 
respective secretions, rationally accounts for the general diminution of se- 



ITS SPECIAL PATHOLOGY. 95 

crctions, and the constant tendency to the accumulation of effete matter in 
the blood, and the steadily increasing deterioration in the quality of that 
fluid. The same change in the force of affinity also lessens the tonicity 
of the tissues, favors passive congestions, hypostatic infiltrations, asthenic 
inflammation, with softening or ulceration, and fatty degeneration. You 
thus perceive that typhoid fever, instead of being a disease of excitement, 
of increased molecular activity from exaltation of the general properties, 
is one of true debility, both in regard to the strength or integrity of 
structures, and the activity of the various functions and processes. This 
view of the nature of the morbid processes constituting the essential 
pathology of this variety of fever, is in harmony with the nature of the 
causes known to favor its development, and also with the morbid anatomy 
or pathological changes in the solids and fluids presented in post mortem 
examinations. It matters not whether the disease is produced by the 
direct influence of the impure air of over-crowded dwellings, damp and 
unventilated places, impure water from soils impregnated with decompo- 
sable organic matter; excessive physical labor, and protracted mental de- 
pression and anxiety; or from some specific poison which may have gained 
access to the blood, it is evident that all these agencies have the tendency 
to depress or impair the properties and functions of the living body. 

Pathological Anatomy. — The changes in the fluids and solids of the 
human body during the p- ogress of a typical case of typhoid fever of or- 
dinary severity, afford a very interesting field for study. The secretions 
and eliminations constituting one class of the fluids, are very generally 
diminished in quantity, as indicated by the unnatural dryness of the cuta- 
neous and pulmonary surfaces, and the actually smaller quantity of saliva, 
gastric juice, and urine, secreted each day during the active progress of 
disease. The pulmonary and cutaneous exhalations vary much, both in 
quantity and quality, in different cases and in different stages of the same 
case. But the nature and extent of these changes, and their relations to 
the progress of the general disease, have not been accurately ascertained. 
The systematic and thorough investigation of these, with the aid of both 
analytical chemistry and the microscope, is worthy of your future atten- 
tion. The renal secretion has already been investigated with much care 
and success. It has been ascertained that the quantity of urine voided in 
the twenty-four hours begins to diminish during the forming stage, and 
continues to decrease during the first week of confinement. In cases 
tending to recovery it increases during the second week, and returns nearly 
or quite to the natural quantity during the third. 

In cases of more than average severity, and in those tending toward a 
fatal termination the quantity of urine voided is apt to vary much from 
day to day during the second and third weeks after the patient is confined 
to his bed. Sometimes the urinary secretion is so nearly suppressed as to 
cause a speedily fatal result. A man was brought into the Mercy Hospital 
only a few days since, in the third week of what appeared to be a. case of 
ordinary typhoid fever. The mind of the patient was dull and incapable 
of giving any reliable history of his case. At the end of twenty-four 
hours it was ascertained that he had two or three intestinal evacuations, 
but had passed little or no urine, and during the following night he had 
general convulsions and died. Alterations in the constituents of the 
urine are also of much importance. The specific gravity is generally in- 
creased in proportion to the diminution in the quantity of urine. The 
quantity of chloride of sodium is decidedly diminished. The sulphuric 
and phosphoric acids are found to remain nearly the same as in health. 
But the urea, uric acid and colored pigment are decidedly increased, not 



96 TYPHOID FEVER. 

only relatively to the quantity of urine, but absolutely above the usual 
quantity of these ingredients in health. The increase of urea and uric 
acid is most marked during the first two weeks from the initial symptoms. 
During the third week it is more varianle, being sometimes above and at 
others below the natural standard. The latter is almost always the case 
during the period of convalescence. Neither the absolute quantity of 
urine voided, nor the relative proportion of its several constituents, have 
been found to bear any fixed or uniform relation to the degree of pyrexia 
or fever heat. So true is this, that in many of the most dangerous cases 
when, during the third or fourth weeks the temperature has risen to 40° or 
41° C. (104:° or 106° F.), the amount of urea excreted in a given time has 
been found so much below the natural standard as to cause just fears of 
uremic poisoning from its retention in the blood. During the first two 
weeks of typhoid fever the urine gives a stronger acid reaction than in 
health. This is caused by the greater concentration from diminution of 
the watery element, and not from an increase in the quantity of acids, for 
the most reliable analyses show the total amount of acids eliminated in the 
twenty-four hours, to be less than in health. In the third and fourth weeks 
of the more dangerous cases, the urine gives a decided alkaline reaction 
from the presence of a fixed alkali. 

Besides the foregoing changes in the natural constituents of the urine, 
albumen has been found in some part of the progress of about one-third 
of the cases examined. In a large majority of these cases, the presence 
of albumen was only temporary, while in a smaller number it continued 
and was associated with renal epithelium, tubular casts and blood cor- 
puscles. And in a verv small number these elements remained after com- 
plete convalescence from the fever, and constituted the beginning of 
Bright's disease. The secretion of bile is generally diminished, as shown 
by examination of the intestinal discharges, though seldom suppressed. 
Dr. Hoffman, who took special pains to investigate the quantity and qual- 
ity of this secretion, found it to be thin and much less colored in one-fourth 
ol the cases examined.* I am not aware of any special investigations 
concerning the composition and properties of the salivary, gastric, and 
pancreatic secretions in continued fever. The general indications are 
that they are decidedly diminished in quantity during all the active or 
advancing stage of the disease. The only source from which an 
increase of secretion or exudation takes place in nearly all the 
cases of typhoid fever, is the mucous membrane of the ilium and colon. 
The intestinal evacuations are very notably increased, as I have stated in 
detailing the symptoms, during all the middle and later stages of the dis- 
ease, and in some cases from the beginning. Such increase, however, is 
not from an increase of the natural secretions from the various glandular 
structures contained in the mucous membrane, but an exudation from the 
locally diseased glands, and consists mostly of the water or serum of the 
blood holding in suspension some mucous, epithelium cells, the debris of 
food and foecal matter, sometimes blood corpuscles, and various saline in- 
gredients. The exudation comes chiefly from the aggregated glands of 
Payer and the solitary glands of Brunner in various stages of asthenic in- 
flammation. 

And though most of the pathologists of the present day, represent the 
so-called typhoid fever germs as existing in the intestinal evacuations of 
patients laboring under that disease, yet no one has thus far been able to 
identify any such germs as peculiar to the discharges in this variety 

* See Ziemssen's Cyclopoedia, Vol. I, p. 106, 



PATHOLOGICAL ANATOMY. 97 

of fever. The blood itself undergoes important changes during the pro- 
gress of this disease. During the period intervening between 1850 and 
1860, I made a careful and somewhat extended investigation of the blood 
at different stages, of both typhoid and periodical fevers. 

1 took from the arms of several typical cases of typhoid fever in the 
wards of the Mercy Hospital under my care, sufficient blood for full chemi- 
cal and microscopical analysis, in the first, second, and third weeks in the pro- 
gress of the disease. I also examined specimens of blood taken from the 
cavities of the heart in some cases resulting fatally. 

It is not prober to occupy your time here with the detail of these inves- 
tigations. I will state the results as follows: To ordinary inspection the 
blood taken during the first week was a shade darker color, than healthy 
venous blood; that during the second, a little darker than the first; that 
t.iken during the third week in bad cases, and that found in the right cav- 
ities of the heart after death, was much darker in hue than either of the 
previous specimens. That taken during the third week from cases tending 
to recovery, had not changed perceptibly in color, frcm that taken earlier 
in the progress of the disease. All the specimens coagulated more slowly 
than healthy blood; the clot formed was larger, softer and more easily torn 
than natural. This diminished coagulability and tenacity of the fibrin 
became more marked, as the disease advanced; and in some of the fatal 
cases the blood remained fluid after death, very dark color, with a film of 
oil over the surface. The clot was not only slow in forming, but contract- 
ed very little after it had formed, and was easily lacerated or broken to 
pieces. The small amount of serum that separated from the clot looked 
more turbid than the serum of healthy blood. Examinations with the 
microscope showed no marked changes except that the red corpuscles ap- 
peared less disposed to adhere together in rows, and some of them were 
corrugated and irregular in outline as if commencing to disintegrate ; 
there was very little, if any, increase in the number of white corpuscles ; 
here and there a fat granule with many specks or shreds of what appeared to 
be the debris of disintegrated corpuscles were seen, more especially in the 
specimens of blood from the advanced stage of severe cases ; and there 
was more or less has matin or red coloring matter in the serum. Careful 
quantitive analysis showed a progressive, though moderate, diminution in 
the relative proportion of albumen, red corpuscles, and chlorides, as the 
disease advanced. On the other hand, the white corpuscles, fatty and ex- 
tractive matters, were moderately increased, while the fibrin varied from 2.2 
to 2.8 parts in 1000, which is nearly the same as in healthy blood. From 
these investigations it appears that the nutritive and formative constituents 
of the blood undergo a progressive moderate diminution in their relative 
proportion as the fever advances through its several stages, and the pro- 
ducts of tissue disintegration increase. If there are any exceptions to this 
rule, it is in the apparent increase in the number of white corpuscles and 
the continuance of the natural proportion of fibrin. I think further in- 
vestigations will show that the increase of the former is derived altogether 
from the lymph in the lymphatic vessels returning matter from the organized 
tissues, and the proportion of fibrin will be found to vary in strict accord- 
ance with the variations in the quantity of- urea and uric acid excreted from 
the kidneys. So long as the quantity of urea continues large, the fibrin 
in the blood will be found at or slightly below the natural standard, and 
vice versa. As you will have seen by the detail I have given, the quality 
of the more important organic constituents of the blood, is impaired to a 
much greater degree in typhoid fever, than the quantity or relative pro- 
portion of each. Ever since the analyses of M. M. Andral and Gavarett, 
7 



98 TYPHOID FEVER. 

authors have represented the fibrin of the blood as particularly deficient in 
both typhoid and typhus.* 

These distinguished investigators in separating the fibrin from the other 
constituents of the blood, practiced the very common method of stirring 
the freshly drawn blood with a bundle of rods for the purpose of entan- 
gling the fibrin on them as it solidifies. This mode is sufficient when the 
fibrin coagulates with its natural degree of readiness and tenacity. But 
I found in the advanced stage of bad cases of typhoid fever, these proper- 
ties of the fibrin so impaired that very little could be gathered upon tho 
rods by diligent stirring for an hour. The same blood, however, when 
allowed to stand at rest three hours or more presented a laro-e, soft clot, 
which, when enclosed in clean, firm linen cloth, and washed under a 
stream of water until all the corpuscles were removed, as practiced 
by Dr. Bence Jones, of London, gave a proportion of fibrin equal to 2.3 
per 1000. These facts have led me to think, the very prevalent idea, 
that the quantity of fibrin in the blood of patients affected with the 
lower grades of continued fever is very deficient is not altogether correct. 
Turning from the fluids to the various organized structures of the body, we 
can find some appreciable changes resulting from protracted and fatal 
cases of typhoid fever, in nearly all of them. In the nervous, muscular, 
vascular, and secreting structures generally, a critical examination aided 
by the microscope, shows some degree of softening or impairment of the 
tonicity and tenacity of the textures accompanied by more or less fatty de- 
generation. These general degenerative changes and impairments of tex- 
ture, are attributed by most writers and teachers to the influence of the 
protracted high temperature, and not to anything belonging to the essen- 
tial pathology of this variety of fever. So far as a high temperature im- 
pairs the force of vital affinity and thereby retards the molecular changes 
in the several tissues, it aids in the work of cell and granule degeneration. 

But you must keep in mind the fact that impairment of the property 
called vital affinity is an essential and primary part of the pathology of 
this fever, and its steady increase during the progress of protracted and 
fatal cases, is abundantly sufficient to cause the general impairments 
of textures without regard to the direct influence of heat, especially when 
aided by the imperfectly oxygenated and decarbonized condition of the 
blood existing in the middle and later stages of all those cases in which 
the capacity of the lungs is diminished both by congestion of the bron- 
chial membrane and hypostatic engorgement of the more dependent portion 
of the lungs. 

I have no doubt but the primary impairment of the vital affinity, the in- 
creased temperature, and the imperfect oxygenation of the blood all co- 
operate in producing the very general softening and molecular degenera- 
tion, that is found in nearly all the organized tissues of the body after 
death from typhoid fever. You will find these general changes, in mak- 
ing ordinary post mortem examinations, most noticeable in the dark 
color and passively engorged condition of the posterior portion of the 
lungs, the softened condition of the muscular structure of the heart; and 
the enlarged and softened state of the spleen and liver. But the special 
pathological changes of structure, universally regarded as character- 
istic of this fever, are found in the aggregated and solitary glands in the 
mucous membrane of the ilium; — the glands of the mesentery; and the 
spleen. 

The aggregated glands of Payer, or elliptical plates, as they are often 

* See Flint's Practice, 5th Ed., p. 951. 



PATHOLOGICAL ANATOMY. 99 

called, evidently become red and tumefied early in the progress of the 
disease. And after death, they are found in all stages of morbid change, 
from simple redness and swelling sufficient to make their outline easily 
recognized, to complete destruction by softening and ulceration until only 
an open ulcer, with abrupt margins, and the muscular fibres of the middle 
coat of the intestine at the bottom, occupies the place where the gland had 
been. The solitary glands of Brunner are generally much enlarged, but not 
often ulcerated. The glands in the mesentery opposite the changes in the 
mucous membrane, are also found increased in vascularity, enlarged, soft- 
ened, and sometimes reduced to a pulpy or creamy consistence. All these 
changes are found in the greatest degree of progress in the lower part of 
the ilium and at its junction with the colon, diminishing as we ascend the 
intestine until at the distance of three metres (ten feet)they are absent alto- 
gether. If you examine these fresh specimens of the lower section of the 
ilium, which have been laid open to expose fully the mucous membrane, from 
the ilio-colic junction upward for a distance of one metre, or about three feet, 
with portions of the mesentery attached, containing several mesenteric 
glands in various stages of enlargement, from the size of a pea to that of 
a hickory nut, you will have a better knowledge of these morbid changes 
than I could impart by any mere verbal description. Beginning at the 
upper part you see several of the elliptical plates of Payer merely reddened 
and elevated by swelling, enough to make their outline easily recognized. 
A little lower, there are others more elevated, with small excavations on 
the surface, indicating the commencement of ulceration. Around and be- 
tween these you see quite a number of single, round, elevated bodies near 
the size of small peas, which are the inflamed and enlarged glands of 
Brunner. Still lower, or nearer to the junction with the colon, you see 
not the glandular structures elevated and undergoing the process of soft- 
ening, but in their place open oval-shaped ulcers, with abrupt and some- 
what irregular margins, and between them the mucous membrane, gener- 
ally redder than natural. Some of the adjacent enlarged mesenteric 
glands I have laid open by an incision, and you see their interior present- 
ing evidences of increased vascularity and in various stages of softening 
with some caseous degeneration. 

There is another shorter section of the lower part of the ilium, not fresh, 
but selected from the wet preparations in the museum, in which you see 
a large ulcer occupying the place of one of the elliptical plates, with a 
complete perforation of the muscular and peritoneal coats. It was taken 
from a patient who was brought into the hospital in a state of collapse 
preceded by all the characteristic symptoms of sudden perforation, general 
peritonitis, and death. The constancy with which these intestinal glands 
are found diseased in making post mortem examinations of typhoid fever 
patients, has led some pathologists to regard them as the essential and 
primary seat of the disease. 

The well ascertained facts, however, that the extent of the disease in 
these glandular structures bears no uniform relation to the severity and 
danger of the general fever, and that the earlier the patient dies from 
some unusual malignity of the fever, the less are the appearances of dis- 
ease in the intestines and mesentery, show the latter to be consequences 
or results of the general morbid actions set up throughout the system. 
And as a rule, the more protracted the course of the fever, the more ex- 
teusive will be the ulceration of the aggregated glands in the ilium, the 
enlargement and softening of the mesenteric glands and spleen, and the 
molecular degenerations of the muscular and nervous structures generally. 
You will not fail to perceive from the detailed description I have given, 



100 TYPHOID FEVER. 

that the entire series of changes taking place during the progress of the 
general fever are in the direction of impairment of tonicity, passive con- 
gestions, molecular degenerations, softening of texture, and ulcerations 
in the glands of the intestinal mucous membrane* Wherever inflammatory 
action is set up, whether in the alimentary canal, the lungs, or the brain, 
it assumes a purely asthenic character, leading directly to tumefaction, 
softening, ulceration or gangrene. Nowhere do we find plastic exuda- 
tions or indurations of structure. In a few instances, small gray depos- 
its, looking much like miliary tubercles, have been observed in the tume- 
fied glands of the ilium. By some they have been called typhus depos- 
its, out their presence does not appear to alter in any way the usual 
tendency to softening and ulceration of these glands, and it is doubtful 
whether they possess any pathological significance. 

Treatment. — From the facts and considerations I have now presented 
to you concerning the causes, clinical history, and special pathology of 
this important general disease, we may see clearly several important in- 
dications to be fulfilled, or objects to be accomplished, in its treatment. 

First, it is desirable to suspend as far as practicable the further action 
upon the patient, of all the causes that may have contributed to the 
development of the disease. 

Second, to restore the natural condition of the general properties of the 
tissues, and thereby retard or arrest those perverted molecular movements 
which constitute the disturbances of nutrition, secretion, excretion, etc. 

Third, to promote the action of certain excretory organs and thereby 
prevent deterioration of the blood by the accumulation of the products of 
tissue changes or waste matter. 

Fourth, to counteract the development of important local diseases, 
either in the head, chest or abdomen. 

Fifth, to sustain the patient with nourishment suitably adjusted, both 
in quality and quantity, to the different stages of the disease. 

These several objects, gentlemen, are not to receive your attention in 
consecutive order of time, as I have named them, but as distinct objects 
to be accomplished in the management of all general acute diseases. They 
should be clearly before your minds at every visit to the bedside of your 
patient, from the beginning to the end of your attendance. 

To fulfill properly the first indication named requires both a proper 
regulation of all the hygienic surroundings of the patient, and, so far as 
the present state of medical knowledge will permit, the administration of 
such remedies as will either neutralize or expel the specific fever poison 
from the system, if such poison exists. To secure for your patient an 
abundance of fresh, pure air, at a comfortable temperature; to secure a 
high degree of cleanliness- by suitable changes of shirts and bed-clothes, 
and frequent ablutions; and to have all evacuations from the kidneys and 
bowels promptly removed from the room; are matters of the highest im- 
portance, and should not be overlooked for a single day in any stage of 
the disease. Unfortunately you will meet with a large proportion of your 
cases of typhoid fever among the laboring classes, occupying small, badly 
ventilated bed-rooms; and in large towns and cities, especially, in tene- 
ment houses or small buildings on narrow streets and alleys, and some- 
times in damp basements. In many such cases a proper supply of fresh 
and pure air is not to be obtained, and you will be obliged to have them 
removed from their homes or treat them under the disadvantage of an in- 
sufficient degree of ventilation. Many of this same class of patients will have 
an inadequate supply of shirts and sheets to permit the changes necessary 
for insuring a healthful degree of cleanliness; and not a few of them will 



TREATMENT. 101 

persist in keeping on two or three coarse woolen shirts all saturated with 
the cutaneous eliminations for a week or more, even if they have a plen- 
tiful supply. It is your duty, however, in all cases, to exercise your 
influence in procuring for those under your care the best degree of ven- 
tilation and cleanliness that the circumstances will permit. By so doing 
you will remove as far as practicable the further action of those influences 
that are generally recognized as predisposing causes. If we admit the 
existence of a specific fever poison in the blood, as the essential or direct 
exciting cause, to suspend its further action requires the use of such 
remedies as will either neutralize the poison or cause its elimination. As 
we have no reliable knowledge, however, concerning the nature and prop- 
erties of this supposed poison, we have no guide for the selection of 
remedies to act upon it. But, in consequence of the known deficiency of 
the chlorine salts in the blood and its defective arterialization, as shown 
by the early and marked deficiency of these constituents in the urine and 
the darker color of the blood, we may give the chlorate of potassium in 
solution, acidulated with the hydrochloric acid, for the purpose of supply- 
ing these deficiencies, and the free chlorine which the solution contains 
will constitute as efficient an antiseptic for destroying organic germs in 
the blood as any we could administer with propriety. Ever since the in- 
genious experiments of M. Bernard, by which it was demonstrated that 
the capacity of the blood for taking up oxygen was increased by the ad- 
dition of the chlorates and other salines, I have used the chlorate of potassium 
in dilute acidulated solution, in the early stage of typhoid fever, and with 
marked benefit. Whether the benefit obtained, is owing to the action of 
the free chlorine on the supposed fever poison, or to the increased amount 
of oxygen taken up from the air-cells of the lungs by the addition of the 
chlorate of potassium to the serum of the blood, or to both, I do not know.* 

That increasing the chlorate of potassium in the blood increases the 
oxygenation of that fluid, I have demonstrated many times, clinically, by 
giving it to children affected with cyanosis from congenital defects in the 
heart. 

That an abundant supply of pure air, not only increases the oxygena- 
tion of the blood and resists the impairment of the quality of its constitu- 
ents, but also greatly improves nervous sensibility and promotes the nat- 
ural molecular changes in all the structures of the body, and thereby 
greatly increases the tendency to recovery from attacks of typhoid and 
other low forms of fever, has been abundantly proved by clinical obser- 
vation. I think it was the uniform experience of members of the medical 
staff of the army during the late war for maintaining the Union, that 
whenever they were obliged to treat their fever patients in tents, or simply 
under canvas, a very much larger ratio of recoveries took place than when 
they were treated in the wards of their best regulated hospital buildings. 

* From the recent investigations of M. Pasteur, concerning the effects of simple dilution and 
exposure to the oxygen of the air, of infectious organic poisons, in lessening their virulence and 
finally rendering them wholly inactive, we derive additional proof that oxygen, is not only an ex- 
citor of organic life, but also one of the most efficient germicides or antiseptics. 



102 TYPHOID FEVER. 



LECTURE XIII. 



Typhoid Fever continued— Treatment. 



GENTLEMEN : At the close of the lecture yesterday, I was directing 
your attention to the several indications to be fulfilled, or objects to 
be accomplished, in the treatment of typhoid fever. I had named five 
such distinct and important objects, and had explained as fully as neces- 
sary the best means for accomplishing the first of the series then men- 
tioned. The second, was to restore the general properties of the tissues 
to their natural condition, and thereby retard or arrest those perverted 
molecular movements which constitute the disturbances of nutrition, se- 
cretion, excretion and calorification, on which the prominent symptoms of 
the disease depend. As I endeavored more fully to explain, when speak- 
ing of the causes and pathology of the fever under consideration, the 
properties of the blood and tissues are impaired from the beginning to the 
end of the disease. 

This impairment is the result of such cause or causes as exert a de- 
pressing influence on the properties and functions, and hence the first 
step in the fulfillment of this second indication is, to remove the further 
action of all such causes by the same means described in the closing part 
of the previous lecture. 

And, if as then indicated, you can from the beginning of the disease 
have the patients supplied with an abundance of fresh, pure air ; suffi- 
ciently sponged over with water daily, to preserve cleanliness and promote 
healthy exhalations from the cutaneous surface ; and supplied with proper 
nourishment, in proper quantities, twenty-nine out of every thirty will 
recover without medication of any kind. But as stated yesterday, a large 
proportion of our typhoid fever patients are found in such condition and 
with such surroundings, that the healthful influences just mentioned can- 
not be secured to the extent necessary for safe reliance, and other means 
must be found for directly or indirectly increasing the susceptibility and 
vital affinity throughout the tissues of the body. Of those agents which 
act directly as excitors of vital affinity, and thereby promote the natural 
molecular changes, none are probably more efficient than oxygen, the 
mineral acids, the chlorine salts — more especially the chlorate of potassium 
— chloride of sodium, bichloride of mercury, iodine, and cold water. 
The practical application of any one of these general excitors must be 
determined by collateral circumstances. For instance, the direct adminis- 
tration of oxygen is inconvenient, on account of its bulk in the gaseous 
form, and the impracticability of trusting its administration to nurses and 
ordinary attendants on the sick. But so far as you can increase the quan- 
tity and purity of the air of the sick room, and by administering judi- 
ciously the chlorate of potassium or chloride of sodium, increase the capac- 
ity of the blood to take up the oxygen from the air-cells of the lungs, in 
the same proportion you will increase the quantity of oxygen circulating 
with the arterial blood and exerting its natural vivifying influence on the 
properties and functions of the system. 

The amount of the chlorate of potassium given, must be so limited as not 
to endanger undue action on the mucous memorane of the intestines. 



TREATMENT. 103 

And the sama remark applies with still more force to the use of the 
chloride of sodium and the bichloride of mereury, but less to iodine, if 
given m the form of aqueous solution or tincture. If you have properly 
studied the nature and action of remedies, you will notice that the agents 
1 hive just mentioned, are not only general excitors of tissue properties, 
and promoters of blood arterialization, but also actively antiseptic, and 
therefore well calculated to destroy any organic fever poison that might 
ex st in the blood. If any among you have become imbued with the pop- 
ular idea that all merecurials merely act on the liver and some other gland- 
ular organs, and depress the powers of life by impairing the plasticity of 
the blood, you will be surprised to hear me mention the bichloride of 
mercury as one of the leading agents for promoting the general properties 
of the tissues and preserving the blood from deterioration. It is now 
nearly forty years since, while listening to a clinical lecture by the late Dr. 
Valentine Mott, I heard that most eminent of surgeons recommend for a 
delicate, pale looking girl, with irritable scrofulous ophthalmia, a combina- 
tion of the bichloride of mercury, with t.ncture of cinchona bark, to be 
taken internally three times a day. And truth compels me to say, gentle- 
men, that through all the changes of medical fashions and prejudices, 
from that time to the present, I have derived more benefit from the use 
of small doses of this preparation of mercury, given in conjunction with 
some of the preparations of cinchona, in the treatment of depressed, de- 
praved and cachectic conditions of the system, than from all the prepara- 
tions of iron, cod-liver oil, and so-called alcoholic stimulants, to be found 
in the list of remedial agents. And strangely enough, at this late day, 
direct experimental investigations have proved that small doses of the bi- 
chloride taken internally actually increase the number of red corpuscles in 
the blood and promote its plasticity. Nevertheless, its practical value in 
the treatment of typhoid fever is limited mostly to the early stage, on 
account of its tendency to increase the intestinal evacuations. The same 
is true in regard to the use of the mild chloride or calomel. Iodine has 
long been known and used as a general alterative and tonic of great value 
in the treatment of chronic affections of a general or constitutional nature, 
and as an efficient antiseptic; but its use has not until very recently been 
extended to the treatment of the general acute diseases or fevers. At the 
present time, however, both iodine and mercury are being urged as spe- 
cific remedies for the cure of typhoid fever. The revival of this idea in 
relation to the specific curative effects of mercury, especially in the form of 
ten-grain doses of calomel, repeated once or twice in the twenty-four hours 
during the early stage of the disease, we owe, as we do the revival of many 
other extravagances, to the profession in Germany. I say revival of the 
idea, because it is no more novel or original at this time than is the use of 
large antipyretic doses of quinine, or the refrigeration with cold water. 
The last named method was thoroughly tested and strongly recommended 
by Dr. Currie, of London, a century since; and as I have stated in a pre- 
vious lecture, quinine has been given in quantities sufficient for the most effi- 
cient antipyretic effect during the first and second weeks of typhoid fever, 
by the physicians of the south and west during the earlier periods of the 
prevalence of that variety of fever in those sections of our country. And 
during the same period, namely, from 1835 to 1850, mercurials in the 
form of calomel and blue mass, were tried with equal thoroughness, in all 
doses from one to twenty grains, and repeated from one to six times in 
the twenty-four hours. I have myself seen, during that early part of 
my professional life, more than a score of cases of typhoid fe^er pretty 
fully salivated from the calomel administered during the first week or ten 



104 TYPHOID FEVER. 

days of their progress. Most certainly, if there had been any specific 
curative power possessed by either quinine or mercurials in the treatment 
of any variety of continued fevers, it should have been so fully demon- 
strated by the practices of half a century ago in this country, that their 
use would have become as firmly established and universal as is the use 
of quinine in the treatment of intermittents. The demonstrations, how- 
ever, were all in the opposite direction so strongly, that even the most 
conservative among us at that time, were rapidly forced from large doses to 
small ones, and from small ones to none at ail. And to complete the history, 
I only need say we passed from no active medicines, or simple expectancy, 
to positive efforts at stimulation, and from food and so-called stimulants, 
we are now gracefully invited back to the fullest doses of active medica- 
tion. It is only necessary now, gentlemen, that some one occupying a 
prominent position in Germany, or some other European State, should 
publish a score or two of cases in which the treatment was commenced 
with an emetic or emeto-cathartic or a moderate venesection, accompanied 
by such a statement of the ratio of mortality as to show better results than 
had been obtained by some other methods of treatment, and the cycle of 
medical progress will be complete, and therapeutics in relation to contin- 
ued fevers will stand very nearly in the same position as half a century 
ago. The principal difference will consist in the lact, that somewhere in our 
professional progress around the circle, we have unconsciously ceased to 
group our remedies under the names of evacuants, alteratives, and anti- 
periodics, and now call them either specific remedies, antipyretics, or 
paraeiticides. 

The third object to be kept constantly in view while directing the treat- 
ment of typhoid fever, is, to so far promote the action of the more impor- 
tant excretory and eliminating organs as to prevent the deterioration of 
the blood by the accumulation of the products of tissue changes, includ- 
ing waste matter and heat. The organs or structures through which the 
greater part of the waste matter derived from ordinary tissue changes, is 
eliminated from the blood and cast out of the system, are the kidnevs, 
lungs and skin. These organs not only eliminate the greater part of the 
natural waste material, but they also eliminate most of the foreign and 
disturbing elements that find their way into the blood from without, and 
also do much to regulate the temperature of the body, by the quantity and 
form of the matter that passes from the lungs and skin. As the functions 
of these several organs are especially liable to be impaired during the first 
two weeks, as I pointed out to you in describing the symptoms and prog- 
ress of the fever, you cannot be too vigilant in observing their condition 
and in adopting such measures as will increase their activity when nec- 
essary. 

Aside from keeping the air of the sick room pure and at a proper tem- 
perature, there is probably no measure better calculated to promote nat- 
ural exhalations from both skin and lungs, than frequent spongings of the 
surface with water of such temperature as is most agreeable to the patient. 
It lessens the frequency and increases the fullness of respiratory move- 
ments, while it reduces the temperature and promotes the exhalations 
from the cutaneous surface. The latter, together with the action of the 
kidneys, may be also materially increased by the administration of proper 
medicines. 

In selecting medicines to promote the action of the skin and kidneys, 
care must be taken to choose those diuretics and diaphoretics that are not 
liable to disturb the bowels. 

Perhaps none are better adapted to the early part of the progress of 



TREATMENT. 105 

typhoid fever than the nitrous ether, the liquor ammoniae acetatis, and the 
digitalis, either separately or in combination. 

The fourth important object which should constantly engage the atten- 
tion of the practitioner while managing this variety of fever, is, to counter- 
act the development or retard the progress of serious local diseases, either 
in the head, chest or abdomen. 

Both clinical experience and post mortem examinations show that much 
the larger number of deaths resulting from this fever are determined by the 
nature and extent of the local lesions which develop in some of the 
most important organs during the progress of the general disease. Con- 
sequently much of your, success at the bedside will depend upon the readi- 
ness with which you detect the existence of complications and the skill you 
exhibit in palliating or removing them. Nor is this all; for when cases come 
under your care early, an accurate knowledge of the natural tendencies to 
develop certain local affections, and a careful examination of the relative 
susceptibility of the different groups of organs in each patient, in connec- 
tion with the season of the year and special sanitary surroundings, will en- 
able you sometimes to so order your remedial measures as to prevent seri- 
ous complications that would otherwise occur. A careful analysis of past 
cli'iical experiences, aided by the results of 2^ost mortem examinations, has 
satisfied me that we have one of three leading sources of danger to encoun- 
ter in all severe cases of typhoid fever, and in some all the three are pre- 
sented in the same patient. 

One of these consists in impairment of the functions of the brain and im- 
portant nervous centres, more especially those centres that govern the ac- 
tion of the vasomotor, cardiac, and respiratory nerves. That the functions 
of the whole nervous apparatus are disturbed, and in many instances pro- 
foundly impaired, is readily seen by the symptoms, and is acknowledged 
by all writers. And yet it has seemed to me that very few have fully ap- 
preciated the importance of that impairment of the vaso-motor influence by 
which the tonicity and action of all the smaller vessels is impaired; passive 
and hypostatic congestions and exudations encouraged, especially in the 
more vascular and distensible structures like the lungs, spleen, and mu- 
cous membranes; or of the impairment of the closely associated centres gov- 
erning the action of the heart, lungs, and sphincters of the rectum and blad- 
der, by which the muscular force of the heart grows weaker, the respira- 
tory movements less steady and efficient, the sphincters weakened, and ul- 
timately paralyzed or relaxed, as the disease progresses through its succes- 
sive stages. It is this progressive impairment of the motion of the blood 
in the smaller vessels and capillaries, co-operating with the general impair- 
ment of vital affinity, that not only favors passive engorgements and exuda- 
tions, but also that softening of texture and fatty molecular degeneration 
described when speaking of the morbid anatomy of the fever. 

It is in these morbid and degenerative processes that much of the water 
drank by the patient is used up, instead of re-appearing in the cutaneous 
and renal secretions. And it is by these same processes and absorption 
of the water that the excess of heat is evolved and the high temperature 
maintained ; the latter being an effect and not the cause of the morbid 
changes in the tissues. 

If I am correct in the expression of these views, then certainly you can- 
not be too vigilant in selecting, or too careful in adjusting such remedies 
as will maintain the sensibility and functional activity of the several nerv- 
ous centres to which I have just alluded. During the early stage of the 
disease you can accomplish this purpose best indirectly by the same agents 
that increase the oxygenation and decarbonization of the blood, increase 



10G TYPHOID FEVER. 

nerve sensibility, and remove the further action of the predisposing and 
exciting causes of fever, as I more fully stated when speaking of the 
means for accomplishing the first and second objects enumerated. But 
when the first stage has passed and the symptoms of special failure in these 
important nervous functions are becoming more prominent, you must find 
some remedies that will more directly and efficiently sustain them. For 
this purpose I have found nothing in the materia medica equal in effici- 
ency to strychnia and the mineral acids. I commenced the use of strych- 
nia in the treatment of the advanced stage of bad cases of typhoid fever 
as early as 1850. At first its use was limited to such cases as began to 
show loss of action in the muscular coat of the bladder or diminished con- 
trol over the sphincters of the body; but further experience showed that by 
commencing its use earlier and continuing it in doses sufficient to act as a 
nerve and muscular tonic, the more extreme and dangerous iailures of 
innervation, as indicated by loss of control over the action of the bladder 
and rectum, very rarely took place. I usually give it in solution with 
nitric acid, and when too much looseness of the bowels exists, I add tinc- 
ture of opium in proper proportion to the mixture. Direct inflammation 
in the nervous centres or their membranous coverings I have seen in but 
few cases of typhoid fever. One such case occurred in the wards of the 
Mercy Hospital a few weeks since, and proved fatal. The best means for 
combatting it are, local bleeding by leeches, cold applications to the head 
continuously, and later, the application of blisters to the neck and mastoid 
spaces. The internal administration of iodide of potassium and digitalis 
may also be used more freely than in uncomplicated cases of the general 
fever. 

In those cases where cerebral symptoms are developed from the reten- 
tion of urea, relief can be obtained only by promoting the elimination of 
the retained poison from the blood by such means as will increase the ac- 
tion of the skin and kidneys. 

The local affections of importance most liable to occur in the chest, are 
extensive hypostatic or passive engorgement of the lower and posterior por- 
tion of the lungs; capillary bronchitis, broncho-pneumonia, and softening 
or degenerative changes in the muscular structure of the heart. When 
either of the three first named pathological conditions are sufficiently ex- 
tensive to greatly lessen the amount of air reaching the air-cells of the 
lungs, it adds very much to the danger of a fatal result. 

The hypostatic engorgement of the lungs, and muscular weakness of the 
heart, are to be counteracted by the same means that increase general ton- 
icity and innervation, as I have already indicated when speaking of the 
means for sustaining the general properties of the tissues, and for main- 
taining the sensibility of the nervous centres. It is in this variety of cases, 
and especially in those characterized by cardiac weakness, that most wri- 
ters and teachers advise the free use of alcoholic remedies, in the form of 
wine, brandy, and whisky. But no fact in therapeutics has been better 
established by direct experimental investigations, than that alcohol when 
introduced into the blood, both diminishes the interchange of carbonic acid 
gas and oxygen in the capillaries and air-cells of the lungs, and the sensi- 
bility of the nervous structures generally. Inasmuch as the blood in the 
class of patients now under consideration is already darker in color and 
less coagulable than natural, and the capacity of the lungs for air dimin- 
ished in proportion to the amount of hypostatic infiltration, while the gen- 
eral sensibility of the nervous systems, both cerebro-spinal and vaso-motor, 
is blunted in a marked degree, it is extremely difficult to see a rational 
basis for the administration of alcohol in any form. 



TREATMENT. 107 

The general idea appears to be, that it directly strengthens and sustains 
the muscular force of the heart. But do carefully observed clinical facts, 
or the results of clinical experience sustain this idea? I have embraced 
every fair opportunity, lor studying this question practically that has oc- 
curred to me during the last thirty-five years; and with due deference to 
the opinions of others, and a full tense of my own responsibility, I must 
answer it in the negative. Neither by cardiac auscultation, nor by the 
disciplined sense of touch, nor by the sphygmegraph, have I been able to 
detect in a single case an aciual increase of cardiac force. When a fair 
dose of wine or brandy is first given it often causes the heart to give from 
five to ten beats more per minute than before, and the sphygmographic 
line will both rise and fall more abruptly, but with less steadiness or uni- 
formity. This apparent excitation, which generally continues not more 
than ten, or at the longest, fifteen minutes, is evidently caused by the direct 
irritative action of the alcohol on the gastric branches of the pneumogas- 
tric nerve, and is evidence of mere temporary disturbance or purturba- 
tion instead of increased strength. In from twenty to thirty minutes, or 
so soon as the alcohol has had time for absorption and circulation through 
the system, it begins to show its true anaesthetic effects on both the cere- 
brospinal and vaso-motor nerves, by calming the patient's restlessness, 
lessening subsultus if it exists, slightly lessening the frequency of respira- 
tion and circulation, and increasing the disposition to sleep. But these 
apparently favorable effects are accompanied by impairment of the vaso- 
motor influence over the whole vascular system, as indicated by relaxation 
of the cutaneous capillaries, lessening- of urinary secretion with more fre- 
quent appearance of albumen in it, softness or compressibility of the pulse, 
and diminished cardiac impulse. And if the doses are repeated at inter- 
vals of one or two hours, so as to keep the effects uniform; the patient con- 
tinues the same general aspect of quietude, but the tone of the vascular 
system becomes steadily more impaired, as indicated by increasing weak- 
ness of pulse, undue sweating, scantiness of urine, increasing size of the 
spleen, more hypostatic engorgement of the lungs, with general sub-mu- 
cous rhonchus, and but feeble efforts to expand the chest, and more drow- 
siness or mental indifference; until, in from one to two weeks after the 
treatment is begun, in many cases the combined influence of the anaesthetic 
effect of the alcohol and the imperfect oxygenation of the blood from 
passive pulmonary obstruction, so far suspends the sensibility of the ex- 
cito-motor nerve centres that the sphincters of the bladder and rectum 
relax, the discharges becomes involuntary, and the patient dies. The 
death in such cases is not from simple asthenia or exhaustion, as is gener- 
ally supposed. For if we compare the amount of nourishment taken in 
the form of milk, beef tea, eggs, etc., with the amount of discharges from 
day to day, we will find that the patient has taken and retained a sufficient 
supply to prevent any dangerous degree of exhaustion. But the fatal 
result is traceable directly to progressive enfeeblement of respiration and 
capillary circulation from failure of the influence of the vaso-motor and 
excito-motor nervous systems, causing loss of tonicity in all the tissues 
and special passive engorgements in the more vascular and distensile 
structures like the lungs and spleen. This final failure of nervous force 
or innervation, and of capillary and molecular changes, is undoubtedly 
owing to the impairment of the quality of the biood and properties of the 
tissues which I have already explained as constituting the essential 
pathology of the disease. What I claim in regard to alcoholic remedies, is, 
that by the anaesthetic effect of the alcohol they contain, they directly in- 
crease the impairment of nerve-force, and by its well known effect in 



108 TYPHOID FEVER. 

lessening the interchange of waste carbonic acid gas for oxygen in the air- 
ceils of the lungs, they increase the blood degeneration and still further 
lessen its power to excite or sustain either nerve-sensibility or molecular 
movements. I might illustrate these effects by the relation of a large 
number of clinical cases from my note-books, but I will trespass upon 
your time for a brief narration of only two, as specimens. 

The first, occurred nearly thirty years since, in the person of a young- 
man in a boarding house on Michigan Avenue, between Lake and South 
Water streets, a section of the city then occupied entirely by residences. 
I was first called in consultation with the attending physician, who related 
to me the history of the case,which corresponded in all respects with the 
history of a typical case of typhoid fever of average degree of severity, it 
being at the time of my visit at the commencement of the third week after 
the patient had taken to his bed. I found him lying on his back; face 
dingy, pale; lips a little retracted and edges slightly purplish, or of leaden 
hue; a little sordes on the exposed part of the teeth; expression of face 
dull and relaxed; tongue covered over the middle and back part with a 
thick, moist coat, but more red and dry at the tip and edges; the cutaneous 
surface was generally moist, cool and of leaden hue over the extremities, 
but above the natural temperature over the chest and abdomen (clinical 
thermometers were not then in use), the latter moderately tympanitic and 
gurgling on pressure; pulse 110 per minute, very soft and weak; respira- 
tions 22 per minute, the expansion of chest by inspiration very imperfect 
with short expiratory act and sudden fall of the abdominal muscles, and 
copious sub-mucous rales over the whole anterior and lateral parts of the 
chest, with decided dullness posteriorly. The urine was sc?.nty, but was 
not tested for albumen; the intestinal evacuations occurred from three to 
six times in the twenty-four hours, were thin, greyish yellow, containing 
white flakes, and during the last twenty-four hours had been only partially 
controlled by the patient. The hearing was dull and the mind very tor- 
pid or inactive, but not delirious. The symptoms that had alarmed both 
the friends and the attending physician, were the rapidly increasing pass- 
ive engorgement of the lungs, with the plain indications of imperfect oxy- 
genation of the blood, feebleness of the pulse, and impairment of the 
action of the sphincters of the rectum and bladder. The patient had been 
fed principally with beef tea and other animal broths during the first week, 
with only a little wine, but during the last preceding five or six days, to 
these had been added a liberal supply of egg-nog and milk punch, contain- 
ing whisky. And as the respiration and circulation became weaker or 
less efficient, the latter was increased until during twenty-four hours pre- 
ceding my visit he had consumed nearly a tablespoonful of whisky every 
hour. As the whole aspect of the case strongly indicated deficient oxy- 
genation and decarbonization of the blood, and the experiments of Dr. 
Prout had fully demonstrated the fact that the presence of alcohol in the 
blood directly diminished the absorption of the oxygen and the elimina- 
tion of carbonic acid gas from the air-cells of the lungs, I suggested to 
the attending physician the propriety of omitting the further use of the 
whisky and all other alcoholic remedies, and trust the case to simple 
nourishment, small doses of quinine, and an emulsion of oil of turpentine 
and laudanum sufficient to keep the intestinal discharges within proper 
limits. He, at once, rather warmly protested that the " stimulants," as he 
called the wine and whiskey, had been the efficient means of keeping the 
patient alive for several days past, and that their withdrawal now would 
be followed by certain, and speedily fatal, prostration. And as I ex- 
pressed an earnest desire to see the experiment tried, he unexpectedly 



TREATMENT. 109 

withdrew from further attendance, and left the case with all its responsi- 
bilities, in my hands. Nothing daunted by this, however, I ordered the 
patient to be fed regularly every hour with two or three tablespoonfuls of 
well prepared porridge, or gruel made of sweet-milk and wheat flour, 
alt 'mating every third dose with an equal quantity of beef-tea, seasoned 
with chlorate of potassium instead of common salt, and for medicine, directed 
sulphate of quinine 0.130 grams (gr. ii) every four hours, alternated with 
oil of turpentine and tincture of opium, each 0.5 cubic centimetre (8 min- 
ims), in the form of an emulsion and immediately stopped all further use of 
alcoholic liquids. I had not then learned the value of stychnia and the min- 
eral acids in such cases, or 1 would have given them instead of the quinine. 
As this was the first time that I had ever come so directly in practical con- 
tact with the question whether alcohol is a supporting or non-supporting 
agent in the advanced stage of typhoid fever, you may be certain, gentle- 
man, that I watched the patient during the next forty-eight hours with an 
uncomfortable degree of anxiety. At each of mv frequent visits I ap- 
proached the patient with trepidation, lest the predicted sinking and col- 
lapse might meet me there. But they never came. On the contrary, at 
the end of twelve hours, I could detect some improvement, both in the 
inspirations and the strength of the pulse. This improvement continued 
very slow but steady, and was sufficient at the end of forty-eight hours to 
relieve me of any further oppressive anxiety. In about eight days, being 
the early part of the fourth week of confinement, convalescence had fairly 
commenced, and the patient made a good recovery. 

The other case, the essential features of which I will relate in as few 
words as possible, came under my observation only a few weeks since. 
The patient was a young man who had passed through a protracted course 
of typhoid fever, partially convalesced, and relapsed, with all the typhoid 
and enteric sj-mptoms severe. I was called to see the patient in consulta- 
tion about eight days after the commencement of the relapse. Found him 
considerably emaciated; face pale; expression dull; a little s >rdes along 
the edges of the lips and teeth; some coating on the back part of the 
tongue, but the mouth generally moist; the skin generally over the trunk 
and extremities most of the time moist, with brief spells of more profuse 
sweating, and feebleness of capillary circulation; the pulse soft, weak, and 
from 100 to 110 beats per minute; respirations variable, but averaging 
about 20 per minute, and attended by less than the normal degree of ex- 
pansion of the chest with each inspiration; resonance on percussion fair 
over the anterior part of the chest, but much diminished posteriorly; a 
mixture of dry and moist sounds detected over nearly all parts of the chest 
by auscultation, with a predominance of the sub-mucous rhonchus. Both 
hypochondriac regions were full; in the left there was considerable en- 
largement of the spleen, as shown by increased area of dullness by percus- 
sion and by detecting its edge projecting a little below the margin of the 
ribs by the touch. The urine was much less than natural, and was stated to 
have been much of the time moderately albuminous since the relapse. 
The intestinal evacuations were near the color and consistence of cream, 
pretty copious, and numbered from three to six in the twenty-four hours, 
but no tympanitic distension of the abdomen. 

The hearing was slightly impaired; the mind torpid or inactive, slightly 
wandering at times, but easily aroused, yet difficult to maintain conversa- 
tion or connected thought. The temperature in the axilla had varied 
during the preceding twenty-four hours from 39° to 40° C. (102.5° to 
104° F.) The extent of passive infiltration or obstruction in the lungs, 
the enlargement of the spleen, the quantity and quality of the intestinal 



110 TYPHOID FEVER. 

discharges, the small quantity and albuminous character of the urine, and 
feebleness of the circulation, taken in connection with the degree of ema- 
ciation and the duration of his sickness, rendered the prognosis very un- 
favorable. The patient had been diligently supported by nourishment 
consisting of milk, beaf-tea and eggs, with which he also took 15 c. centi- 
metres, or half an ounce of brandy every two hours, making 180 c. centi- 
metres (fvi) in the twenty-four hours. He had taken it nearly at the same 
rate during the seven or eight days since the relapse. He was also tak- 
ing two-grain doses of quinine every four hours, with an emulsion of tur- 
pentine and laudanum between to control the intestinal discharges, and a 
solution of acetate of potash to increase the action of the kidneys. As the 
treatment had been instituted and thus far carried on by two excellent 
physicians, whose opinions were entitled to full respect, I did not feel dis- 
posed to abruptly demand a change in regard to the use of the brandy, more 
especially as the previous consulting physician was not able to be present. 
I consequently suggested no changes, either in medicine or nourishment, 
except the addition of strychnia and nitric acid, in moderate doses, every 
four hours, in hope of improving the sensibility and tone of the nervous 
and muscular structures. The case progressed for three or four davs with 
no marked changes, except the intestinal discharges became gradually 
less frequent and darker color, the urinary secretion was variable, some- 
times quite free and again scanty, with a large excess of phosphatic depos- 
its; the temperature also varied one or two degrees every twenty- four 
hours, but at no time rose above 40° 0. (104° F.). The circulation and 
respiration, however, became gradually more impaired by the steady in- 
crease of passive infiltration in the lungs, more feebleness of pulse, and 
more relaxation and sweating. During the fourth or fifth night after my 
first visit, the symptoms of exhaustion became so alarming that the nurse 
gave, on his own responsibility, an extra amount of brandy over that I 
have mentioned. When I met the attending physician the following 
morning, we learned that the patient had passed a rather restless night, 
had two thin intestinal evacuations, had passed very little urine and 
none had accumulated in the bladder, but had spells of profuse sweating, 
accompanied by symptoms of great feebleness. 

The whole cutaneous surface was still wet with a cool, clammy sweat; 
pulse very weak, and circulation in the smaller vessels slow and imperfect, 
respiration short, with very little expansion of the right side of the chest; 
and no evidence by auscultation that the air-cells of the lung were inflated 
during inspiration; diminished resonance over the whole of that side of 
the chest, and the posterior part of the left, but considerable inflation, 
with sharp sub-mucous rhonchi in all the anterior and lateral part of the 
left lung. The systolic action of the heart was short and weak. The 
aspect of the patient was such as to render it probable that he would not 
live another day unless some improvement could be made in the functions 
of respiration and circulation. Being fully satisfied that the alchohol in 
the brandy he was taking, by its anassthetic effect on the nervous struc- 
tures, and its interference with the decarbonization of the blood, was posi- 
tively adding to the embarrassment of the respiratory and circulatory func- 
tions, I advised that the quantity given should be immediately diminished 
one-third, while the strychnia, nitric acid and emulsion should be continued, 
and an effort made to improve the circulation and check the sweats by the 
tinctures of digitalis and belladonna — two parts of the former to one of the 
latter — given in doses of one cubic centimetre (15 minims) every three 
hours. This advice was strictly followed, and instead of any " sinking" as 
so many anticipate from the lessening of the quantity of brandy, the next 



TREATMENT. Ill 

morning tlfere was a notable improvement in both the respiration and cir- 
culation. The patient had rested more quiet, the sweating being much 
diminished and the urine increased in quantity. The sub-mucous rhonchi 
were some less in the left side of the chest, and a little more expansion of 
the right by inspiration. 

The quantity of brandy was still further diminished one-half, and in two 
days it was discontinued altogether; in all other respects the treatment 
was continued the same. 

The respiration and circulation continued to improve slowly for two 
days, and subsequently very rapidly with coincident improvement in all 
other respects, and in four or five days convalescence was fairly estab- 
lished. I have thus briefly related to you the first and the last cases of 
typhoid fever in which I have had opportunity for carefully noting both 
the effects of giving alcoholic remedies regularly and efficiently, and the 
effects of their entire discontinuance at an advanced and critical stage of 
the disease. During the quarter of a century or more that has intervened 
between these two cases, I have had many similar opportunities for study- 
ing the effects of these remedies at the bedside of fever patients, and 
almost uniformly with similar results. The only exceptions were three 
cases characterized by morbid vigilance or sleeplessness, mental anxiety, 
rapid pulse, and muscular trembling. 

In these, pretty full doses of diluted alcohol, given in the form of milk 
punch, produced sufficient anaesthetic effect to induce sleep and quiet the 
undue nervous excitability, after which it was gradually withdrawn. But 
the use of almost any other reliable anaesthetic would have produced the 
same results. I repeat, therefore, that in all ordinary cases of typhoid or 
other general fevers, the continued use of alcoholic remedies, either fer- 
mented or distilled, from day to day, instead of strengthening the action 
of the heart and sustaining the functions of the system, positively adds to 
the embarrassments of respiration and capillary circulation and diminishes 
nerve sensibility, thereby favoring both passive congestions in the lungs, 
spleen and kidneys, and fatty degeneration in the muscular structure of 
the heart. The third group of local diseases that should engage your 
constant attention while attending cases of typhoid fever, are found in the 
alimentary canal and mesentery. But we must take still another hour to 
complete the consideration of this important subject. 



LECTURE XIV. 

Typhoid Fever Concluded— Treatment, Complications and Sequalae. 

GENTLEMEN: At the close of the lecture yesterday I was about to di- 
rect your attention to the indications f r treatment specially present- 
ed by the pathological changes in the alimentary canal which accompany 
most of the cases of typhoid fever. The most important of these changes, 
as I have already described to you, consist in asthenic inflammation, tume- 
faction, softening and ulceration of the aggregated and solitary glands of 
the lower half of the ilium, the enlargement and softening of the mesenteric 



112 TYPHOID FEVER. 

glands, the spleen, and in a lesser degree the liver. Of these, the disease 
of the glands in the mucous membrane of the intestine is of paramount 
importance both on account of the interference with the 'nourishment of 
the patient and the exhausting diarrhceal discharges that generally accom- 
pany it. Yet many of the writers and teachers of the present day appear 
to inculcate the idea that these extensive morbid changes in the ilium are 
only the efforts of nature to eliminate the supposed fever poison through 
the glands of Payer and Brunner, and consequently the resulting diarrhceal 
discharges are to be encouraged rather than repressed, especially during 
the first week of the patient's confinement. 

There is no more evidence, however, that the inflammation and other 
destructive changes in these glands have anvthing to do with the elimina- 
tion of a specific fever poison, than there is that the inflammation of the 
fauces and glands of the neck in scarlatina is a conservative effort of na- 
ture to eliminate the poison of that disease, or that the contagium of measies 
escapes from the irritated mucous membrane of the nostrils and bronchial 
tubes. 

If the disease of the glands of Payer and Brunner served the purpose 
of eliminating from the blood a specific fever poison that had induced the 
general fever, then the earlier they become involved in any given case 
and the more free the diarrhoea during the first week, the shorter and 
milder should be the subsequent progress of the disease. But neither my 
own clinical experience nor the recorded observations of others show any 
such result. On the contrary, it may be stated, as a general rule, that the 
earlier the indications of intestinal disease appear in the progress of the 
general fever and the more copious the diarrhoea, the more severe and pro- 
tracted will be the course of the general disease. The proper course is to 
regard the pathological changes in the ilium, mesentery, and other abdom- 
inal organs, as important complications of the general fever, capable by 
their extent and severity of adding much to the danger of fatal results, 
and consequently to be watched for and early met by such remedies as are 
capable of limiting their extent and mitigating their severity. 

In selecting remedies to counteract these intestinal lesions, you must re- 
member that their special characteristics are strictly asthenic. We have 
first passive congestion from impaired tonicity of the vessels, accompanied 
by aplastic exudation and tumefaction; next softening of texture, and third 
ulceration, disintegration or sloughing, accompanied throughout by morbid 
sensibility, and generally by increased peristaltic motion. To counteract 
these pathological conditions you must bring to your aid such remedies as 
will increase the natural tonicity or contraction of the vessels, and at the same 
time lessen both the morbid sensitiveness and exaggerated peristaltic mo- 
tion. The use of some anodyne conjointly with, at first (in the incipient 
stage) small doses of mercurials or iodine; next with one of the mineral 
acids, nitrate of silver, or oil of turpentine, and throughout the middle and 
later stages, the last mentioned remedy and strychnia, fulfills the rational 
indications presented better than by any other means with which I am ac- 
quainted. The object is not merely to lessen the amount of the intestinal 
discharges, but to limit or arrest certain dangerous pathological changes in 
the glandular structures both within and without the intestines. This can- 
not be done by a simple styptic or astringent influence. If it could, any of 
the stronger astringents, as tannin, gallic acid, acetate of lead, or persulphate 
of iron would answer our purpose. These, however, tend to check secre- 
tions generally and are productive of more harm than good, except when 
used temporarily for the arrest of actual hemorrhage. But the mineral acids, 
nitrate of silver, oil of turpentine, and strychnia, improve the tonicity of 



TREATMENT. 113 

the smaller vessels, lessen passive congestion and exudation, and arrest the 
tendency to softening and disintegration, by increasing the general 
property oi" the tissues, called vital affinity, or by increasing the vaso-motor 
nervous influence, or by both. Hence they improve natural secretory ac- 
tion while they lessen unnatural discharges from passively congested tis- 
sues. The distinction I here make is one of much practical importance, 
and yet I fear it has been often overlooked. 

The fifth and last general indication or object that I have named to you 
as requiring the constant attention of the practitioner while managing the 
treatment of typhoid fever, is, to sustain the patient with nourishment 
suitably adjusted, both in quality and quantity, to the different stages of 
the disease. The accomplishment of this object in the best manner, re- 
quires a correct knowledge of the constituents of different articles of food, 
the facility with which they can be taken up from the surface of the stom- 
ach, duodenum and first half of the small intestines, with little or no fecal 
residue to pass over the more irritable and diseased surface of the ilium, 
and the readiness of their conversion into the nutritive constituents of the 
blood capable of being applied to the repair of wasting tissues. The fol- 
lowing brief propositions may aid you in the study of this subject. First 
choose such articles for nourishment as, either separately or conjoined, 
shall contain all the elementary constituents entering into the composition 
of the blood and organized structures of the human body. Second, the 
article or articles selected should be so prepared, that when taken into the 
stomach they are capable of being taken up and assimilated with but little 
influence from the gastric and other secretions usually required for the 
digestion and absorption of ordinary food in health, because these secretions 
are generally much diminished, especially during the middle and later 
stages of the disease. 

Third, the quantity given at any one time should be so limited that it 
will be all absorbed or assimilated before any part of it has time to un- 
dergo fermentation or putrefactive changes by which the tympanites, and 
the irritation of the glandular patches in the ilium, might be increased; 
and yet the aggregate quantity given in the twenty-four hours must be 
sufficient to afford the patient a fair degree of support. 

The practical application of this rule requires, on the part of the attend- 
ing physician, a discriminating judgment founded on an accurate knowl- 
edge of the condition of the digestive organs of his patient, and entire 
faithfulness on the part of the nurse. 

I have sometimes thought that more typhoid fever patiejits had been 
lost from errors in feeding than in the administration of medicines. At 
one time they are starved to death on beef-tea and so-called beef juices 
and essences, which contain little else than the water, soluble salts, and 
aroma of the meat; and at another they are literally stuffed daily with 
enough beef-tea, milk, egg-nog, and brandy or whiskey punch, to give a 
healthy day laborer a fit of indigestion. You cannot exercise too much 
care in avoiding both these extremes. As a general rule, well prepared 
meat broths from either beef, mutton or chicken, suitably seasoned with 
salt, constitute the best nourishment during the first three or four days 
after the patient takes to his bed, and the quantity allowed to be taken at 
one time may be safely left to the inclination of the patient. After this, 
milk should be alternated with the beef-tea or used altogether as a substi- 
tute for it; and so soon as the patient begins to exhibit that mental dull- 
ness which makes him indifferent or averse to taking food, the nourish- 
ment should be given at stated intervals and in prescribed quantity as 
regularly as the administration of medicines. In the middle and later 
8 



114 TYPHOID FEVER. 

stages of the disease, when the bowels are more or less tympnnitic and 
the intestinal discharges thin and frequent, the milk should be boiled 
and, while boiling, a little wheat flour added with brisk stirring to pre- 
vent its forming lumps, and give it the form of a thin, homogenious milk 
and flour gruel. From two to four tablespoon fu Is of this may be given 
every one or two hours, and it constitutes the best nourishment for such 
cases that I have been able to devise. It contains all the elements necessa- 
ry to supply the waste of the bioodand tissues in small compass, bland and 
soothing to the mucous membrane, and easily assimilated. For drinks, noth- 
ing is better than milk-whey, fresh buttermilk, and cold water, given in small 
quantities but sufficiently often to keep the mouth, tongue and fauces from 
becoming too dry. When there is much muttering delirium with subsultus, 
or unusual drowsiness, tea and coffee, as pure excitants of nerve-sensibil- 
ity, will constitute valuable drinks. 

Some of you may be surprised that I have not included in the list of 
important objects to be accomplished in the treatment of typhoid fever, 
that of controlling the temperature by antipyretics. The omission is only 
apparent, however. The increase of temperature being simply a symp- 
tom or result of those complex molecular and functional disturbances 
produced by the action of the predisposing and exciting causes on the 
blood and general properties of the tissues, the only rational and curative 
mode of controlling it, is by removing the further action of such causes, 
and restoring the disturbed molecular and functional actions to their nor- 
mal condition, as I explained in the preceding lecture, while speaking 
of the first, second and third objects requiring your attention. To seize 
upon one leading symptom of a general acute disease involving many 
important morbid processes, and make its control the principal object of 
treatment, without any regard to the morbid processes on which it de- 
pends, is both unphilosophical and often attended by bad results. You 
might with the same propriety fix your attention on the diarrhoea that so 
generally attends the middle and advanced stages of the disease, and 
endeavor to control it by opiates, astringents, or whatever would most 
speedily suppress it, without, regard to the special character of the mor- 
bid processes in the intestines by which it was produced, as to take your 
clinical thermometer in hand and undertake to arbitrarily control the tem- 
perature of your patient by cold baths, quinine, digitalis, salicylic acid, 
or whatever else would most speedily reduce it within the desired limits, 
without regard to the effect of your remedial agents, or antipyretics, on 
the blood, the nervous centres, or any of the other important processes 
involved. Do not infer, gentlemen, that I am undervaluing either the 
use of the clinical thermometer or of the various remedies called anti- 
pyretics. The introduction of the former into use at the bedside has added 
much to the accuracy of our knowledge concerning the range of tem- 
perature in acute diseases, and the connection of that range with import- 
ant pathological conditions, and the new modes of using the latter have 
led to much better results than the prevalent method of stuffing almost all 
continued fever patients with wine, egg-no<r, and whiskey or brandy 
punch, that immediately preceded it. This latter fact, however, does not 
prove that these better results, are as good as might be obtained by a more 
discriminating use of remedies. I would warn you against trusting too 
exclusively to the guidance of the clinical thermometer on the one hand, 
and the too indiscriminate application of powerful remedial agents to the 
control of a single symptom on the other. I have seen several fatal cases 
•of typhoid fever in which the daily use of the thermometer by the attend- 
ing physician failed to make a single registration above 40° C. (104° F.). 



TREATMENT. 115 

One o( those died from perforation of the intestine at the end of the fifth 
week from the commencement of the disease.* 

That the arbitrary use of antipyretics is often accompanied by dan- 
gerous results, T have abundant evidence from direct clinieal observation. 
Jt is only a few months since I saw a case of uncomplicated typhoid fever, 
in the second week of its progress, in which a cold pack was directly fol- 
lowed by a protracted chill and the development of a dangerous degree 
of pneumonia. Within the last three or four years I have been called to 
three eases under the care of three different practitioners, in which 0.66 
grams (gr. x.) of sulphate of quinine had been given every hour until 
"3.0 grams (gr. xxx.) had been taken to reduce the temperature, twice in 
the twenty-four hours, for a week in succession. Two of the patients 
were adults, the other a child of about twelve years. In each case, at the 
time of my visit, which was from three to five hours after the last dose of 
the quinine had been given, the patients were found in a dorsal position, 
limbs extended, features relaxed and pale, profoundly deaf, the respira- 
tion so feeble that the motion of the chest was hardly perceptible, and 
the circulation alarmingly feeble ; yet in neither case was the temperature 
below 38°3. C. (101° F.). 

By omitting the further use of quinine and substituting therefor small 
doses of strychnia and nitric acid, with such other' remedies as the condi- 
tion of the intestinal discharges and urinary secretion indicated, the more 
dangerous symptoms disappeared during the succeeding twenty- four hours, 
and in due process of time the patients recovered, i have also seen a 
number of cases in which the most alarming symptoms of prostration ac- 
companied the use of salicylic acid in the second week of the progress of 
the general fever. 

One of these occurred in one of my own wards of the Mercy Hospital. 
A laboring man, aged about 30 years, during the first half of the second 
week of his confinement, had been taking 0.66 grains (gr. x.) of salicylic 
acid in solution with bicarbonate of soda, every four hours, when his 
pulse went rapidly down to 45 beats per minute, with all the accompany- 
ing symptoms of great exhaustion. The remedies were changed, and the 
svmptoms of extreme depression slowly disappeared. After two or three 
days, the temperature of the patient being too high, and not feeling 
certain that the previous bad symptoms had been caused by the salicylic 
acid solution, its use was resumed, and in about forty-eight hours the 
same symptoms were again suddenly developed. Of course, the further 
use of the remedy was omitted; the disease continued through a pro- 
tracted and severe course, but finally ended in convalescence. If by 
these observations I can induce you to faithfully use your clinical ther- 
mometers as the most accurate mode of determining the temperature of 
your patients, that you may carefully compare it with the progress of 
the morbid processes on which it depends; and to so study the modus 
operandi of the several antipyretics, that you may see clearly which is 
best adapted for the removal of such morbid processes and conditions as 
may give rise to arf increase of the sensible heat or high temperature, I 
shall have conferred a great benefit, both upon you and your future 
patients. 

Having thus led you through a detailed, and perhaps tedious, analytical 
study of the several important indications to be fulfilled or objects to be 
accomplished, in the treatment of typhoid fever, for the purpose of ena- 

*Dr. Frantzel has recently described several cases of typhoid fever, which run their course with 
low temperature, but prese'nted serious cerebral symptoms, general collapse, and sometimes gan 
grene ot the lower extremities. See Zeit. fur Klin. Med., Band ii.. S. 217. 



116 TYPHOID FEVER. 

bling you to comprehend more fully, both the nature and extent of the 
morbid processes presented, and the philosophy of their management, it 
only remains for me to reverse this order, and by a synthetical union of 
indications and remedies, briefly conduct you through the actual treatment 
of some fair sample cases, as though we were at the bedside of the pa- 
tients. When called to a fair typical case of typhoid fever during the 
first one or two days after the patient has taken to his bed, presenting the 
symptoms I have already described to you as belonging to that stage, I 
endeavor to secure the best possible hygienic surroundings for the pa- 
tient, by fresh air, strict cleanliness, and two or three times a day a spong- 
ing of the cutaneous surface with water at such temperature as is most 
agreeable to the patient. For still further modifying the general disturb- 
ances of secretion and excretion I order the two following prescriptions: 

3 Hydrargyri Chloridi Mitis, 0.40 grams gr. vi. 
Pulveris Opii Compositi, #.00 " " xxx. 

Potassii Nitratis, 2.00 " " xxx. 

Mix, and divide into six powders, one to be given every four hours. 
fy LiquorisAmmonii Acetatis, 60. c.c. §ii. 
Spiritus iEtheris Nitrosi, 60. c.c. %\\. 
Mix, and give 4, c. centimeters, or one tea-sj^oonful every four hours 
between the powders. 

After continuing these remedies for twenty-four hours, if there have 
been no evacuations from the bowels, I order an enema of warm water, 
holding in solution a little common salt, or sulphate of magnesia, which 
will usually procure one or more free evacuations. If it is not convenient 
to have an enema administered, a mild saline laxative may be given by 
the mouth. The further use of the powders is limited to one every even- 
ing for two or three nights, after which they are entirely omitted. As 
soon as the bowels have been fairly moved, either spontaneously or by the 
use of the mild laxative measures just mentioned, I direct a solution of 
chlorate of potassium with hydrochloric acid in gum arabic water, in such 
proportion that 15 cubic centimeters (3SS.), or one table-spoonful, will con- 
tain from 0.33 to 0.50 grams, (gr. v. to gr. viii.) of the chlorate, and the 
same number of minims of the hydrochloric acid, and have this amount 
given every four hours, alternating with the liquor ammonise acetatis, and 
the spirits of nitrous aether. These remedies and such frequent sponging 
of the surface with water as the heat and dryness may indicate, I continue 
so long as the abdominal tympanitis remains only moderate, and the in- 
testinal discharges do not exceed one or two in the twenty-four hours. 
In many mild cases the patients pass through the disease to an early con- 
valescence with no other medication. But the more severe cases seldom 
reach the end of the first week after taking to the bed, without showing 
increased fullness of the abdomen, more dryness of the tongue, and an 
increase of the intestinal discharges. As soon as these symptoms make 
their appearance, 1 omit the farther use of the prescription containing the 
liquor ammonias acetatis, and substitute in its place the following emulsion. 



I£ Olei Terebinthinae, 


12. c. c. 


3iii- 


Olei Gaultheriae, 


2. " " 


3ss. 


Tincturse Opii, 


15. " " 


3iv. 


Pulveris Acaciae, ) . . 
Sacchari Albi ) 






25. grams. 


3vi, 


Rub together thoroughly, and add 






Aquaa 


120. c. c. 


iiv. 



TREATMENT. 117 

Mix thoroughly and give 4 cubic centimeters (3i), or an ordinary tea- 
Bpoonful every three, four, or six hours, according to the frequency of the 
discharges. If this emulsion is faithfully prepared in the manner 1 have 
just stated, it is not unpleasant to take and very rarely disagrees with the 
stomach or irritates the urinary passages, even when continued for ten 
days or two weeks without interruption. And in nine cases out of every 
ten, if its use is commenced as early as I have indicated, and continued 
judiciously, it will do more to limit the extent and finally arrest the pro- 
gress of the morbid changes taking place in the intestines and glands of 
the mesentery than any other remedies that I have used. Yet, I occasion- 
ally meet with a case in which the oil of turpentine either offends the 
stomach or causes painful micturition ; and if either of these effects follow 
its administration, 1 immediately discontinue it and give instead one of the 
following formulas: 

fy Argent! Nitratis 0.66 grams gr. x. 

Extracti Hvoscyami 2.00 " " xxx. 

Pulveris Opii " 2.00 " " xxx. 

Mix intimately and divide into pills xxx ; one of which may be given 
just as often as you would otherwise give a dose of the emulsion. 

Or, fy Acidi Sulphurici Aromatici 15. <xc. 3iv. 

Magnesiae Sulphatis, 15. grams. * 3iv. 

Tincturae Opii, 15. c.c. 3iv. 

Aquae, 120. " |iv. 

Mix and give four cubic centimeters {fl. 3) or one teaspoonful in a little 
additional water, every three or four hours, instead of the pills or 
emulsion. You will perceive that each of these three formulae combine 
two leading properties: one capable of increasing the tone of the congested 
vessels in the diseased glandular structures without checking any of the 
important secretory and eliminative processes; the other capable of directly 
lessening the morbid excitability of the same structures and thereby lessen- 
ing the morbid intestinal discharges. Their administration should be so 
graduated in size of dose and frequency of repetition as to limit the intes- 
tinal evacuations as near as possible to one or two in the twenty-four hours 
until they become consistent and natural. If it should happen that the 
evacuations from the bowels entirely cease for twenty-four or thirty-six 
hours at any time after the commencement of the second week, do not 
commit so great a blunder as to administer a dose of physic to provoke 
them. In such cases nothing more is necessary than to suspend the use of 
the restraining measures, or at most administer a warm water enema. The 
giving of even the mildest physic in the advanced stage of typhoid fever 
is always attended by danger to the patient. It is only a few weeks since 
that I was called to see a young man who had passed nearly through a 
pretty severe course of the fever, and defervescence had actually com- 
menced, when, on account of the failure of the bowels to move for thirty-six 
hours, a moderate dose of sulphate of magnesia was given, which not only 
operated promptly and freely, but was followed by a renewal of tympanites 
and intestinal discharges so frequent and persistent that fatal exhaustion 
was induced in a few days. If the measures I have now indicated fail to 
exercise sufficient control over the general febrile condition and at any 
time during the latter part of the first or in the second week the tempera- 
ture rises to 40° C. (104.5° F.) accompanied by some delirium, restlessness, 
quick pulse, and dryness of the mucous membrane of the mouth and air 
passages, I wrap the patient in a wet sheet and keep up refrigeration by 



118 TYPHOID FEVER. 

frequently sprinkling the shoet with cold water until the temperature falls 
to 30° C. (102.5° F.). This process may be resorted to once or twice in 
the twentv-four hours in aid of the ordinary sponge baths, so long as the 
temperature continues to rise for anv considerable part of the day above 
40° 0. (104.5° F.). 

If from the inherent gravity of the disease or the neglect of proper meas- 
ures in the earlier stages of its progress, the patient begins to exhibit a 
low, muttering delirium, or a dull, drowsy mental condition, with more or 
lesssubsultus, a quick, weak pulse, a slowness in expelling the urine, or 
an imperfect control over the sphincters of the rectum and bladder, I 
promptly direct the administration of strychnia and nitric acid, and gen- 
erally in accordance with the following formula : 



3 Strychnine, 


0.066 grams. 


gr. i. 


Acidi Nitrici, 


4. c.c. 


3i. 


Tincturae Opii, 


15. " " 


3iv. 


Aquae, 


105. " " 


§iiiss 



Mix and give 4 cubic centimeters (3i), or a tcaspoonful in sweetened 
water every three, four or six hours, according to the urgency of the 
symptoms. At the same time the administration of such nourishment as 
1 have already indicated should be faithfully attended to. The region of 
the bladder sliould be examined at every visit, and if it fails to empty 
itself completely the catheter should be used at proper intervals. 

If the abdomen remains very tympanitic and the intestinal evacuations 
too frequent, a dose of the turpentine and laudanum emulsion may be given 
between the doses of the strychnia solution, until those symptoms are suf- 
ficiently restrained. 

If, finally, signs of defervescence begin to appear, and all the bad symp- 
toms abate, do not discontinue your remedies suddenly, but simply 
lengthen the interval between the doses from time to time until convales- 
cence is fully established and the urinary and intestinal discharges have 
become natural in quantity and quality. The foregoing brief outline of 
treatment, coupled with the previous full discussion of the indications to 
be fulfilled, both in the typical and untypical cases, is sufficient for all 
ordinary purposes. But there are some important symptoms or complica- 
tions that occasionally present themselves during the progress of typhoid 
fever, the management of which needs some attention. For instance, 
there are cases in which diarrhoea and other abdominal symptoms are 
prominent from the commencement. In such cases, instead of giving the 
chlorate of potassium and hydrochloric acid, I direct at once the turpentine 
and laudanum emulsion or some one of the formulae for allaying the intesti- 
nal irritation, and for an antiseptic and alterant to modify the general 
properties of the tissues, iodine may be given in solution with iodide of 
potassium, as in the following formula : 



^ Iodinii 


0.5 grams. 


gr. viii. 


Potassii Iodidii 


2,0 " " 


" XXX. 


Aquae Purae 


30.0 c.c. 


" p. 



Mix, and give from 0.3 to 0.5 c. c. (minims 5 to 8) every six hours, in a 
tablespoonful of sweetened water. In all grave cases of the general fe- 
ver, the action of the kidneys should be noted carefully, and if the urine 
either becomes very scanty or albuminous, or both, an infusion of digi- 
talis leaves, holding in solution acetate of potassium, administered in fair 
doses once in four hours, will be found one of the best remedies. The 



HEMORRHAGE AND PERFORATION. 119 

giving of this need not interfere with the use of any other remedies indi- 
cated in th.> case at the same time. Sometimes, in the advanced stages 
of the fever, the patient becomes subject to profuse and exhausting 
sweats, coincident with scanty urine and feeble pulse. To check this I 
have found a combination of the tincture of digitalis, two parts, with one 
part of the tincture of belladonna, given in doses of 1.5 cubic centi- 
metres (minims v.w.) every two, three or four hours, more promptly effi- 
cient than anything else that I have used. I have also found this sama 
combination useful in lessening the extreme tympanitic distension of the 
abdomen, from apparent loss of action in the muscular coat of the intes- 
tines, in two cases recently under my care in the Mercy Hospital. You 
will remember that when speaking of the symptoms of typhoid fever, T 
stated that some rare cases were met with, in which, instead of dullness 
and drowsiness, we had morbid vigilance or constant wakefulness, with 
nervous agitation, and sometimes delirium. 

To allay these unpleasant symptoms I have given the tincture of digi- 
talis and chloroform, each 0.5 to 1.0 c. c. (minims viii. to xv.) every two 
or three hours, with the effect of soon inducing quiet sleep and a marked 
improvement in the general symptoms. In milder cases of the same 
kind, pretty full doses of hyoscyarnus and camphor have been sufficient to 
procure the needed rest, especially when given in the evening. 

Intestinal Hemorrhage. The occurrence of true intestinal hemorrhage 
as distinguished from the simple intermixture of a small quantity of blood 
with the fecal evacuations, is not of frequent occurrence, though occasion- 
ally met with at any part of the progress of the disease after the middle of 
the second week. Its occurrence is always an unfavorable indication, and 
generally leads to a speedy and fatal collapse. The blood, when voided, 
is generally very dark color, partially coagulated, and emitting an offensive 
odor. For arresting the hemorrhage, oil of turpentine, acetate of lead, 
gallic acid, ergotine, and nearly all the more important vegetable astring- 
ents, have been given both by the mouth and rectum, and sometimes with 
success. In the few cases that have come under my own observation, 
better success has attended the administration of the persulphate of iron 
in doses of 0.130 grams (gr. ii) dissolved in water, every hour; at the 
same time continuing the ordinary use of the turpentine and laudanum 
emulsion. 

Perforation of the Intestines. The extension of the ulcerative process 
in some one of the aggregated glands of the lower part of the ilium, so far 
as to cause perforation of all the coats of the intestines, and the production 
of general and speedily fatal peritonitis, is liable to occur at anytime during 
the last sta^e, or even in the convalescence, of protracted cases of typhoid 
fever. This accident or complication is certainly not of frequent occur- 
rence, as I have met with but two instances in my own patients during the 
whole period of my practice. The first of these occurred in 1851, in the 
person of a young man who was studying medicine. He had passed 
through a regular course of typhoid fever, and convalesced at the end of 
the third week. After progressing with his convalescence nearly a week 
apparently well, and being up a part of each day, he was taken suddenly 
with very sharp pains in the central part of his abdomen, followed by a 
great sense of prostration, a very quick and weak pulse, rapid increase of ten- 
derness and distension of the abdomen, and all the symptoms of general peri- 
tonitis, under which he died in less than forty-eight hours. The other 
occurred during the fourth week of a severe case, before any signs of con- 
valescence had appeared. The treatment of such cases consists mainly in 
the administration of opiates sufficient to hold the intestines quiet and 



120 TYPHOID FEVER. 

lessen the pain, in the hope that adhesive inflammation may be set up in the 
peritoneal surface around the perforation, and by quickly causing the parts 
in contact to adhere together, prevent the contents of the intestine from 
becoming diffused in the peritoneal cavity generally, and thereby so limit 
the progress of the inflammation as to afford the patient a chance of recovery. 
It is possible that some cases have terminated thus fortunately. But as a 
general rule, perforation of the intestines in connection with typhoid fever, 
has proved speedily fatal in despite of any treatment hitherto adopted. 

Sequehe. The three most important pathological conditions liable to 
result from a severe and protracted course of typhoid fever, are chronic 
diarrhoea from imperfectly repaired ulcerations in the ilium; permanent 
impairment of the capacity of the lungs for air through failure to regain 
the full expansion or reopening of the air-cells in those parts of the lungs 
which had suffered either from protracted hypostatic infiltration, or more 
likely from a low grade of pneumonic exudation during the progress of 
the fever; and a condition of general debility characterized by loss of 
power of endurance and almost constant tendency to constipation and 
moderate inactivity of secretions generally, without any well defined 
local disease. Such patients usually say they feel very well as long as 
they refrain from any active labor, but tire out as soon as they commence 
work. I have traced many such cases back directly to attacks of typhoid 
fever that had occurred several years previously. It has seemed to me 
that in these cases the various organized tissues had never regained the 
full activity of the elementary properties that govern those molecular 
changes which are concerned in nutrition, secretion and innervation. 
Consequently all these processes and functions are conducted on a lower 
grade of activity than natural. Yet most of this class of patients are al- 
most constantly dosed, either with supposed cholagogues, to act on the liver 
and remove "biliousness," or with some kind of alcoholic "bitters" to 
promote strength and appetite, or both alternately. Under such treat- 
ment they generally get gradually worse from year to year. There are 
two rational indications to be fulfilled in the treatment of these patients, 
namely, to increase the tone and sensibility of the nervous and muscular 
structures, and to promote cell growth or molecular change. To fulfill 
the first I give a pill containing strychnia 0.002 grams (gr. 1-32), sulphate 
of iron 0.064 grams (gr. i) before each meal-time; and for the second, the 
syrup of the lacto-phosphate of lime 4 cubic centimetres (fl. 3i.) afcer each 
meal. If the bowels are decidedly costive, pulverized aloes 0.016 
grains (gr. J) may be added to each pill during the first week. The 
continuance of these remedies, with a proper supply of good air, very 
moderate but regular out-door exercise daily, and a fair variety of plain 
food, for two or three months, has seldom failed to re-establish a fair grade 
of health and strength. 

The second class of patients named as recovering imperfectly after ty- 
phoid fever, had their disability founded on an imperfect restoration of 
the air-cells, after protracted closure from infiltration or exudation during 
the middle and later stages of the general fever. The exact condition of 
the affected portions of the lungs appears to consist in hypertrophy of the 
connective tissue with obliteration of many of the air-cells, constituting a 
condition styled by the waiters of a former generation, carnified. 

The patients suffer chiefly from inability to take active exercise without 
shortness of breath, and from the ordinary consequences of habitually im- 
perfect oxygenation and decarbonization of the blood. The pathological 
change of structure being permanent, the treatment must be altogether 
palliative; and consists mainly in adjusting the daily exercise and diet of the 



SEQUELS. 121 

patient to his actual capacity for enduring the one, and assimilating the 
other. If the defect is only moderate in amount, the health of the patient 
may remain in statu quo for many years. But if the impairment of struc- 
ture is extensive, it is very liable to cause further degenerative changes, 
especially of a fatty or caseous character, bringing the symptoms and 
consequences of one form of phthisis. 

Some degree of chronic diarrhoea, as a sequel of the general fever, is 
met with more frequently than either of the other defects of which 
I have just spoken. You must remember that defervescence often takes 
place while there is still considerable looseness of the bowels, and it is 
not very uncommon to see one or two soft or semi-fluid evacuations for 
several days after the patient appears to be convalescent. If this is neg- 
lected and a liberal diet allowed, the patients will gain slowly in flesh and 
strength, and in a few weeks get about their ordinary business, though 
still having from one to three loose stools per day, and not feeling as 
strong as they think they ought to. After two or three months, instead of 
having fully recovered, they find themselves losing both in flesh and 
strength, and are again compelled to seek medical advice. 

It is now found that they are having a regular chronic diarrhoea. The 
stools are generally thin, greyish or reddish brown in color, and occurring 
from one to four or five times in the twenty-four hours, and are usually 
accompanied by little or no pain. In some, nearly all the evacuations 
take place in quick succession during the morning, and the bowels remain 
quiet the rest of the day. In others, an evacuation follows almost immedi- 
ately after each meal, as though the presence of food in the stomach 
excited an undue peristaltic movement throughout the whole length of the 
alimentary canal. Occasionally you will meet with a case that presents 
regular alternations of costiveness and diarrhoea ; the bowels remaining 
quiet from two to three days, with an increasing sense of fullness or discom- 
fort, and then free diarrhceal discharges for one day, or until the contents 
of the bowels have been fully discharged. During the war, from 1861 to 
1864, a very obstinate, and sometimes fatal, form of chronic diarrhoea was 
often met with among the soldiers, as the sequel of protracted attacks of 
typhoid fever, modified by the co-existence of malarious influences, called 
by many " typho-malarial fever." I need hardly remind you that the 
diarrhoea found following an attack of typhoid fever has its origin in the 
continuance of a morbidly sensitive condition of the recently ulcerated 
glandular structures in the lower part of the ihum, and in the more severe 
cases the continuance of the ulcerated patches in a more indolent or 
chronic form ; but I repeat the fact, for the purpose of again urging the 
importance of having the practitioner give close attention to the careful 
regulation of both diet and medicines through the period of convalescence, 
and until the intestinal discharges have become reliably natural, both in 
time and quality. It is far easier, by such attention, to prevent this 
troublesome and sometimes dangerous sequel, than to cure it after it has 
become established. Yet, the great majority of the cases I have met with 
have recovered in from two to six weeks by a properly regulated diet of 
milk and wheat-flour gruel, milk and light bread or crackers, and meat 
broths made with rice added to the meat, aided by much rest in the recum- 
bent position, and a dose of either the turpentine and laudanum emulsion, 
or of the nitrate of silver, hyosciamus and opium pills each morning, noon, 
tea-time and at bed-time. The number of doses per day may be dimin- 
ished from time to time, as the discharges become less frequent and more 
consistent. In such cases as had continued until the blood had become 
much impoverished of red corpuscles and nutritive elements, giving the 



122 TYPHUS FEVER. 

patients a very anaemic appearance, as was the case with many of the 
soldiers returning sick from the military camps, I obtained very good 
results from the administration of a powder every four or six hours, com- 
posed of sub-nitrate of bismuth 0.5 grams (gr. viii.), sub-carbonate of iron 
0.2 grams (gr. iii.), and sulphate of morphine 0.011 grams (gr. 1-6). In 
some of the same class of patients, in which the morphine in the powders 
induced secondary nausea and depression, I substituted, with advantage, 
the use of a solution of bromine with bromide of potassium and distilled 
water, as in the following formula : 

l£ Brominii 0.66 c.c. M x. 

Potassii Bromidi 4. grams. 3i. 

Aqua) Distillatae, 120. c.c. §iv. 

Mix, give 4 cubic centimetres (fl. 3i.) or one teaspoonful further diluted, 
with at least a tablespoonful of water every four or six hours. The use of 
this remedy was first suggested to me as valuable in chronic diarrhoea and 
dysentery by the surgeon in charge of the hospitals in connection with the 
military camp on Rock Island, towards the close of the war. This, gentle- 
men, completes what I have thought important to say to you concerning 
typhoid fever, which is the most important because the most universally 
prevalent of all the more severe acute general diseases. 



LECTUKE XV. 

Typhus Fever— History, Causes, Symptoms, Diagnosis, Prognosis, Special Pathology, Pathologi- 
cal Anatomy and Treatment. 

GENTLEMEN : — Typhus fever has been recognized and described 
under various names, from the earliest periods of medical history. 

The word typhus means dullness or stupor, and was for a long period 
applied equally to the typhoid fever, as to that now more distinctively 
recognized as typhus. It was not until the early part of the present cen- 
tury that the work of separating the two diseases was fairly begun and 
prosecuted with great care. Prominent among those who have contributed 
to the establishment of diagnostic differences between them are Dr. Enoch 
Hale, of Massachusetts, in 1833 ; Dr. Gerhard, of Philadelphia, in 1835 ; 
Dr. A. P. Stewart, in 1840 ; M. Louis, of Paris, in 1841 ; Dr. E. Bartlett, 
of Massachusetts, in 1842 ; Dr. Austin Flint, of New York, in 1852 ; and 
still later, Sir William Jenner, of London. The careful and extended re- 
searches of the latter have been considered sufficient to demonstrate the 
fact that the typhoid and typhus fevers are essentially distinct and in- 
dependent types of continued fever, by a large majority of the profession. 
This conviction, however, is by no means universal, for there are still some 
who regard them as modifications of one disease caused by differences in 
the intensity of the action of the causes, rather than by essential and 
specific differences in their nature. 

Assuming that typhus is a distinct form of general fever, we find the 
range of its prevalence much more limited than that of the typhoid type. 



HISTORY. 123 

And it is claimed that it has its home or natural habitation in Ireland, 
Poland, and the Russian provinces bordering on the Baltic, as distinctly 
as yellow lever has in a part of the Atlantic Coast and the West India 
Islands. Certain it is, that no other part of the civilized world has been 
so frequently and generally scourged by the epidemic prevalence of typhus, 
as Ireland. " According to Dr. Hirsch the disease was generally prevalent 
throughout the island from 1797 to 1803, in 1815, from 181? to*1810, 182 L 
to 1822, 1825 to 1827, in 1834, 1836, 1842, and from 1846 to 1818. The 
same author states that during the years 1817, 1818, 1819, not less than 
800,000 in a population of 6,000,000 fell sick, and 45,000 died. The deaths 
wore not all from typhus, for a considerable number came to their death 
directly from famine and dysentery. 

The disease not' only finds a home in the localities just named, but it 
appears to have accompanied the Irish emigrant into almost every other 
country of Europe and America. 

Dr. Flint tells us that it was imported from Ireland, and began to pre- 
vail as an epidemic in New York in 1861, and from that time to 1864, 
1428 cases were admitted into the Bellevue Hospital alone.* I will not 
occupy your time, however, by any detailed history of the appearance and 
progress of this variety of fever in different countries, or even in our own 
country. It is sufficient to state that in most cases where emigrant ships 
have sailed, either from Ireland, or some parts of the continent of Europe, 
with such numbers of emigrants on board as to greatly overcrowd the 
ship, typhus fever has made its appearance among' them before they 
reached this side of the Atlantic, and often caused the death of large 
numbers; and those who survived introduced the disease into whatever 
port or town they were permitted to enter. 

These results were so common during the former years of active immi- 
gration into our own country, that the disease came to be familiarly styled 
"ship fever," or "ship typhus." Xew York, Boston, and Philadelphia, 
were the chief primary receptacles for this tide of humanity and the dis- 
eases accompanying it. 

But as large numbers who were not actually sick on their arrival, took 
passage by railroad immediately for the West, or some town in the inte- 
rior, some of them would commence being sick on the route, or soon after 
their arrival. In this way the disease has been freshly introduced into a 
great many localities throughout the interior of the country. I have re- 
peatedly met with cases in this city among those who had just arrived by 
railroad from New York, having- passed almost directly from the emigrant 
ship to the cars. Typhus fever, however, has been observed in many 
places in our country, from the severe epidemic in 1807 in Xew England, 
to the present time, and under circumstances when it could not be traced 
to any foreign source, or channel of communication with other infected 
localities. 

Causes. — It is claimed by most of the writers and investigators of the 
present day, that typhus fever not only originates solely from a specific 
organic poison, but that the poison is reproduced in the bodies of the sick, 
constituting* it a true contagion. 

All agree that the disease is found chiefly in circumstances character- 
ized by the presence of confined and foul air, caused by want of cleanli- 
ness and ventilation, overcrowding, poverty and famine. Crowded ships, 
jails, prisons, poor houses, asylums, manufacturing establishments, narrow 
and crowded streets in cities, and poorly supplied camps of armies, are 

* See Practice of Medicine, by Austin Flint, M. D., fifth edition, page 971.— 1831. 



124 TYPHUS FEVER. 

the places in which typhus has been found to chiefly prevail in all past 
periods of medical history. In other words, it is the same kind of circum- 
stances, only existing in a more concentrated degree, that favors the 
development of typhoid fever, as I have already pointed out to you in the 
lectures on that subject. Most of the advocates of a specific typhus con- 
tagion claim that all the bad hygienic conditions to which I have alluded 
are only predisposing or favoring circumstances, and in no case capable 
of originating the disease until the specific fever germ has been introduced 
from without. Yet all such are forced to admit that absolutely nothing 
is known concerning the " nature, form, and condition of said germ," * 
and abundant instances have been observed in which cases of the disease 
have occurred under circumstances admitting of no possible connection 
that could be traced, with any outside source of infection. 

Dr. Austin Flint reported four cases of typhus that occurred in the Erie 
county almshouse in the winter of 1840-1, that strikingly illustrate this 
fact.f and many others, equally well observed and reliably recorded, 
might be cited, of the same import. Giving due credit to all well ascer- 
tained facts concerning the origin and spread of typhus fever, without 
allowing undue weight to mere theoretical opinions, I have been led to 
the following conclusions: 

First, the disease is capable of originating from the use of an atmos- 
phere strongly impregnated with the excretions and effluvia from the hu- 
man body, without any traceable communication with other sources of 
infection, as in the many instances in which caies have occurred in alms- 
houses, jails, ships, and other over-crowded places, so far isolated that it 
was hardly possible for any infection or specific germs to have been in- 
troduced from without and not be easily discovered. To persist in assum- 
ing that the germs mast have been introduced from some foreign source, 
merely to sustain a favorite theory, is contrary to the true spirit of scien- 
tific inquiry, and is much less rational than the position so ably main- 
tained by the late Dr. Joseph M. Smith, in his report on hygiene, in the 
third volume of the Transactions of the American Medical Association, 
namely: that the concentrated organic matter in the air of such places, by 
further decomposition, developed the special poison that caused the dis- 
ease. 

Second, the disease when once developed, is capable of spreading by 
contagion or direct communication from one individual to another when- 
ever many cases are crowded together in the same hospital ward, or the 
air is allowed to remain unventilated in the room of a single patient. 
But, whenever thorough ventilation and cleanliness are maintained in the 
sick room, the propagation by contagion or direct communication with the 
sick is of rare occurrence. 

Third, the essential cause or materies morbi that produces typhus, 
though originating under circumstances very similar to those giving rise 
to the cause of typhoid fever, nevertheless produces its eifects more rap- 
idly, causing a more profound alteration in the quality of the blood and 
excretions, and consequently more readily contaminating the air sur- 
rounding the sick with infectious effluvia, capable of developing the same 
disease in those who may inhale it. 

Typhus fever is generally greatly increased in its prevalence in seasons 
of famine, and by all such circumstances as tend to keep either families 
or larger numbers closely indoors with inadequate ventilation. Conse- 
quently limited outbursts of the disease have occurred more frequently in 

* See Practice of Medicine, by Roberts Bartholow, M. D., etc, etc., second edition, p. 705. 
f See Boston Medical and Surgical Journal for June, 18-41. 



SYMPTOMS. 125 

the winter or seasons of protracted cold. Otherwise it appears to be but 
little influenced by age, sex, or seasons of the year. 

Symptoms. — The symptoms that accompany typhus from its initial stage 
to convalescence, are so closely analogous to those of typhoid fever, that it 
is only necessary to call your attention to the differences, instead of the 
symptoms in detail. The initial stage of typhus is shorter, usually not 
more than from two to five days, and is characterized by the same feelings 
of dullness, headache, and general indisposition, and more frequently ends 
in a marked chill, as the patient takes to his bed. During the first three 
or four days the face is more deeply suffused with a dingy redness ; more 
congestion of the surface generally ; a more rapid rise of temperature ; 
greater frequency of pulse and respiration ; and more tendency to early 
delirium, than in the typhoid fever. As the disease progresses, the tongue 
becomes more thickly coated, and changes earlier to a dark brown color, 
w r ith more sordes on the lips and teeth; more congestion of the vessels 
of the conjunctiva; a continuance of more frequency and feeble- 
ness of pulse ; and in cases marked by much stupor the pupils are often 
much contracted, with earlier and more marked subsultus. The symp- 
toms referable to the respiratory organs do not differ materially from 
those of the typhoid disease ; while those indicating disturbance of the 
alimentary canal are much less. In fact, there is more frequently consti- 
pation during the first week in typhus, than any degree of diarrhoea, and 
in many cases the bowels are disposed to remain quiet throughout the 
w 7 hole course of the disease. As a rule, the abdomen is much less tym- 
panitic and more doughy or inelastic to the feel, and without gurgling; 
and both the eliptical plates in the ilium and the glands of the mesentary 
remain but little altered. Yet in quite a large proportion of the cases of 
typhus, the second week is accompanied by considerable diarrhoea and 
some tympanites. The urine undergoes the same changes as in typhoid 
fever, being on the average more scanty, and albumen present in a larger 
proportion of the cases. 

As a general rule, the skin and bronchial membranes are dry, but in 
some cases periods of copious sweating occur at different times during 
their progress. Both epistaxis and intestinal hemorrhages are very rare 
in typhus. The average range of temperature differs but little from that 
of typhoid fever. It rises more rapidly and generally reaches its climax 
about the fourth or fifth day, when it is generally from 40° to 41° C (104° 
to 106° F.), according to the severity of the case. From that time to the 
end of favorable cases the morning temperature is about 38°. 8 C. (102° F.), 
and the evening 39.5° 0. (103.2° F.) In the cases tending towards a fatal 
result the average temperature is usually one or two degrees higher. A 
rapid decline in the temperature towards the end of the second week gen- 
erally indicates the near approach of convalescence. The average fre- 
quency of circulation is also greater, the pulse ranging from 100 to 130 
per minute, and the respirations are more frequent than in the typhoid 
disease. The average duration of typhus is also less, being about two 
weeks, while the extremes vary from seven days to twenty-eight or 
thirty. 

The defervescence is more rapid and often accompanied by critical evac- 
uations from the skin, kidneys or bowels. 

Perhaps the only symptom accompanying typhus, that has been claimed 
to be different in kind as well as in degree, from the corresponding symp- 
tom in typhoid fever, is the eruption or maculae on the skin. Eruptions 
appear on the skin in a certain proportion of both forms of fever. They 
appear earlier in typhus, usually from the third to the fifth day, are more 



126 TYPHUS FEVER. 

copious and more generally diffused both on the trunk and extremities. 
They are smaller, darker colored, less elevated, and after the first few days 
the color does not disappear on pressure, and in bad cases, towards the 
close of the disease they often become petechial. 

These spots, however, are often absent throughout the whole course of 
the disease. Dr. Murchison states that they were absent in 11 per cent, 
of the cases admitted to the London fever hospital. In 65 cases observed 
by Dr. Austin Flint, they were absent in 12 per cent. Dr. Lebert makes 
them absent or only slight in 20 per cent, of his cases. My own observa- 
tions have led me to think that the importance- of the eruptions or spots 
on the skin, has been greatly overrated both in typhoid and typhus. 
They are not only absent in very many cases, and so slight as to require 
close examination to find them in many more, but both kinds are some- 
times present and freely intermingled on the skin of the same patient, at 
the same time. 

Diagnosis. — You cannot fail to notice, gentlemen, that in what I have 
said concerning the symptoms of typhus, the differences from those of the 
typhoid disease, are all expressed in terms indicating more or less; that is, 
differences in degree and not in kind. And you will find the same charac- 
teristic in all your works on practical medicine. There is, therefore, no 
absolutely reliable diagnostic symptom by which all cases of typhus can 
be readily distinguished from typhoid fever. The strongly marked typi- 
cal cases of both varities present sufficient points of difference to make 
them easily distinguishable. But practically the gap between these is 
filled by cases from both sides, less and less differing, until the symptoms 
become so merged and intermingled that the most experienced clinical 
observers are left in doubt as to which side of the diagnostic line they 
should be placed. Hence, M. Louis, Jenner, Flint and others who have 
analyzed any considerable number of cases for the purpose of proving the 
non- identity of the two varieties of fever, have been obliged to set aside 
from seven to ten per cent, of the whole number, in a doubtful list, or 
defer the completion of their diagnosis, until after & post mortem examina- 
tion could be made. 

These facts certainly show a very close relationship, if not an essential 
identity, between these two varieties of acute general disease. 

Prognosis. — From the statistics of mortality gathered by Dr. Murchison 
in the leading hospitals of London, Edinburg, Glasgow, Paris, and the 
provinces of France, the average ratio of mortality appears to be 18.78 
per cent., or 1 in 5.27. About the same results are given by Lebert, in 
his article on Typhus in Ziemssen's Cyclopaedia of Practical Medicine. 
You will notice that these ratios are almost identical with those furnished 
from the same sources in typhoid fever. There are great differences in 
the ratio of mortality in epidemics occurring in different places, and in 
different years in the same place. In some instances only 8 or 9 per cent, 
have died, while in the London Fever Hospital in 1850, according to 
Murchison, the death rate rose to 60 per cent. As is usual in all epidemic 
diseases, the ratio of mortality has been found greater at the beginning 
than during the decline of an epidemic. It is slightly higher in males 
than in females; and much greater in adults than in children. There are 
many facts on record indicating that the mortality from typhus is greatly 
influenced by the amount of fresh air supplied to the patient. A single 
patient occupying a large and well-ventilated room, or an open tent, not 
only doubles his chances of recovery compared with one in a small, im- 
perfectly ventilated room or a crowded hospital ward, but he very rarely 
communicates the disease to those who come in contact with him. This 



SPECIAL PATHOLOGY. 127 

was strikingly illustrated when, in 1864, the fever cases, mostly typhus, 
were transferred from the Bellevue Hospital in New York, to tents on 
Blackwell's [si and. In the hospital wards the ratio of deaths had been a 
little more than one in six, but when over 500 had been treated in the 
tents, it was found that the ratio was only a fraction more than one in 
Be von teen. 

Sptcial Pathology. — As in all other relations, so in regard to the 
special pathology, there is a close analogy between the typhus and typhoid 
forms of lover. The morbid changes in the blood, the general properties 
of the tissues, the processes of nutrition and disintegration, and in the 
functions of the more important excretory organs are in the same direc- 
tion in both. It has seemed to me that the essential cause or causes of 
typhus acted in the same direction, but with greater intensity, than those 
of the typhoid disease. Consequently, in typhus we have a more rapid 
development of the disease, a more profound alteration in the quality of 
the blood, a greater depression of the susceptibility and vital affinity of 
the organized structures, causing earlier and more decided disturbance of 
nervous functions, capillary circulation and secretion, and an earlier ter- 
mination either in death or recovery. When death takes place, it is more 
generally from the direct and extreme impairment of the quality of the 
blood, and of the properties of the tissues, rather than from local compli- 
cations; and recoveries are more frequently marked by critical evacuations. 

Pathological Anatomy. — The post mortem appearances presented in 
cases of typhus differ from those found after death from typhoid fever, 
chiefly in two particulars. First, the blood in typhus is more decidedly 
dark colored and uncoagulable, and all its constituents more impaired. 
This was fully demonstrated by Dr. Upham, of Boston, in a paper givino- 
in detail the results of a large number of jiost mortem examinations in 
the emigrant fever hospital on Deer Island, near Boston, several years 
since. Second, the glandular structures in the mucous membrane of the 
ilium and mesentery are much less changed in typhus than in typhoid 
fever; and in some instances they have undergone no appreciable changes 
whatever. In many cases, however, the glands of Peyer have been found 
congested and sufficiently tumefied to render their outlines distinct, and 
in a few, some degree of ulceration was present.* In all other respects, 
the description I gave you concerning the pathological changes in typhoid 
fever, will apply equally well to those found after death from typhus, and 
consequently I need not repeat it at this time. 

Treatment. — The indications to be fulfilled in the treatment of typhus, 
and the means for fulfilling them, are the same as in the typhoid form of 
fever. And as these were very fully discussed while considering the 
treatment of the latter disease, it would be a needless repetition to renew 
the discussion at this time. As the fever develops more rapidly in typhus, 
and the morbid changes in the blood are more prominent, so the three 
first objects to be accomplished in its treatment, as mentioned in relation 
to typhoid fever, should receive your most prompt and careful attention. 
To secure for each patient an abundance of good air, cleanliness, and such 
sponging of the surface as the dryness and heat may indicate, are meas- 
ures of primary importance. General alteratives, antiseptics, and mild, 
laxatives are more needed, and may be given with more freedom during 
the first week than in the typhoid form of disease. On the other hand, 
as there is little or no indication of intestinal disease in the majority of 
cases of typhus, you will have less opportunity for giving the turpentine 

* See Ziemssen's Cyclopaedia of the Practice of Medicine, Vol. I., p. 334. 



128 THE PLAGUE. 

emulsion and other remedies recommended for relieving the intestinal 
complications. But in all such cases as are accompanied by too much 
looseness of the bowels in any part of their course, these same remedies 
will be found the most efficient for relieving it. In all other respects, the 
directions I have given you in relation to the management of typhoid 
fever are equally applicable to the corresponding stages of typhus. 

Prophylaxis. — To prevent the propagation or spread of typhus, the 
utmost care should be exercised to maintain full ventilation and scrupu- 
lous cleanliness; to avoid all over-crowding or the aggregation of many 
patients in close proximity to each other; all excretions or evacuations 
should be immediately removed from the room; and no more well persons 
admitted to the presence of the patients than is necessary for giving them 
proper care and treatment. 

THE PLAGUE. 

The next acute general disease, to which I will call your attention, is 
one that has thus far never been recognized as having an existence in our 
country or on this continent. 

I allude to the Pest, or Plague, which, previous to the middle of the 
seventeenth century, was one of the most severe and fatal scourges of the 
human race. The words Pest, Pestilentia, and Plague, were originally 
used to designate any severe epidemic disease; but in more modern times 
they are used only to designate a severe and malignant form of continued 
fever which has generally been supposed to have its home in Egypt, Syria, 
and countries bordering on the eastern shores of the Mediterranean Sea, 
and the rivers that empty into it. There are evidences of its having pre- 
vailed in those countries from a very remote period of antiquity. From 
there it repeatedly spread over Europe and Asia, but the first extensive 
prevalence of the disease throughout Europe of which we have a reliable 
history, occurred about the middle of the sixth century, and is known as 
the Plague of Justinian. During the ten subsequent centuries it fre- 
quently prevailed in an epidemic form over large portions of Europe, Asia, 
and Africa, and in some places destroyed more than half of the entire pop- 
ulation during a single epidemic. Several times it visited both London 
and Paris. After the middle of the seventeenth century it began rapidly 
to recede from western Europe; and after the important sanitary improve- 
ments in and around Cairo and other parts of Egypt, under the reign of 
Mohamet Ali, its prevalence became so limited that it hardly attracted 
attention in any part of the world. It is not extinct, however, as we have 
accounts of its prevalence among the Arabs in North Africa in 1858 and 
1859; in Mesopotamia in 1867; in Persian Kurdistan in 1871, and in some 
of the provinces overrun by the armies during the late war between Rus- 
sia and Turkey, in the southeastern part of Europe and the border of Asia 
during the last two or three years. 

Causes. — Liebermeister classes the Plague among the contagious-mias- 
matic diseases; and if we give full credit to the statements of those who 
have witnessed its prevalence in different places and seasons, it would 
appear to be capable of direct communication from one person to another 
by contagion, and also of being developed and propagated in the midst of 
impure air, uncleanness, overcrowding and famine. In these respects it 
bears a close analogy to typhus; and, like the latter, is very rarely con- 
tagious, except when many patients are aggregated together in dwellings 
or hospital wards, or where both ventilation and cleanliness are neglected 
in the room of a single patient. 



SYMPTOMS. 129 

That bad social conditions coupled with damp, ill-ventilated, and over- 
crowded dwellings, aided by a soil undrained, and permeated by foul 
water are capable of developing specific poisons of various degrees of ac- 
tivity or virulence, which, when imbibed by human beings are capable of 
producing typhus, plague, yellow fever, and perhaps other pestilential 
diseases, I have no doubt. That such specific poisons are also capable of 
being reproduced in the emanations from the bodies of those sick with 
the diseases named, provided they remain in bad sanitary surroundings, 
and under such circumstances may prove highly contagious, appears to 
be proved by abundant historical facts. But facts equally abundant fur- 
ther prove that no amount of such specific poisons can be propagated or 
made to spread disease in the midst of pure air and good sanitary regula- 
tions. The plague seldom prevails sporadically, but very generally as- 
sumes an epidemic form, and varies much in its severity and fatality in 
different epidemics. Neither age, sex, nor season of the year exert any 
notable influence over the development and progress of the disease. 

Symptoms. — Those who regard the disease as caused exclusively by a 
specific organic poison imbibed from without, represent the period of in- 
cubation to be between two and seven days. 

The commencement of active symptoms is generally marked by a chill, 
or at least rigors, which soon give place to fever characterized by pains 
in the head, back and limbs, much restlessness, great sense of weakness, 
dizziness, sometimes vomiting and purging, with inward burning and 
great thirst. The skin soon becomes hot and dry; the eyes injected ; 
tongue covered with a white chalky-looking coat ; pulse from 110 to 120 
per minute, and breathing correspondinglv accelerated ; and the temper- 
ature often from 39.4° to 40° C. (103° to 104° F.) before the end of the 
first twenty-four hours. During the second and third days the symptoms 
present all the characteristics of profound typhus, and are usually followed 
on the third and fourth days by the appearance of inflammation and swell- 
ing of the lymphatic glands in the groins, armpits, or neck. These swell- 
ings attain a size varying from that of a pea to that of a hen's egg ; and 
if the patient does not die before the end of the first week, suppuration in 
some of the swellings is apt to occur. Simultaneously with the appear- 
ance of the glandular swellings, carbuncles are also liable to appear on 
the back, hips and extremities. In a large proportion of cases the pa- 
tients sink early into a constant delirium, stupor, or coma, with small, 
feeble, irregular pulse, and die between the third and fifth days. If they 
live beyond the first week, the fever declines, such swellings as have sup- 
purated discharge, at first an unhealthy pus with considerable destruction 
of areolar tissue ; and if carbuncles have formed, their sloughs begin to 
separate, the dryness and sordes disappear from the mouth and lips, and 
the patients slowly recover, though some die from exhaustion during the 
suppurative stage, after the general fever has disappeared. In some cases 
occurring during the height of a severe epidemic, the patient has exhibited 
sudden and extreme paleness of features, great feebleness of cardiac action, 
imperfect respiration, coldness of surface and extremities, and has died in 
a few hours without any establishment of febrile heat. 

Dia gliosis. — The plague is distinguished from typhus, and still more 
from the typhoid fever, by the greater abruptness of its beginning, the 
more rapid rise of temperature and greater violence of all the symptoms 
during the first two days, and subsequently by the appearance of pains 
and swellings in some part of the lymphatic system of glands, to which 
are added in many cases, carbuncles on the back and extremities. The 
9 



130 THE PLAGUE. 

whole course of the disease is more violent, and shorter in duration, than 
any other variety of continued fever. 

Prognosis. — As I have already stated, when alluding briefly to the his- 
tory of the disease, the prognosis is extremely unfavorable, its prevalence 
being accompanied by a larger proportion of deaths than from any other 
known acute general disease. 

In those great epidemics of the disease that prevailed over nearly all 
the known countries of Europe, Asia and Africa, in the middle of the 
sixth century called the "Plague of Justinian;" in the middle of the four- 
teenth called the u Black Death;" and about the middle of the seven- 
teenth century, nearly three-fourths ot" those attacked, died. As a gen- 
eral rule, if the patient lives beyond the seventh day from the commence- 
ment of the attack, his chances of recovery are much improved. Neither 
age nor sex appears to exert any marked influence over the ratio of mor- 
tality. 

Special Pathology. — All the symptoms accompanying the plague in- 
dicate the presence of some morbid material or special poison in the 
blood, which by its presence impairs both the quality of the blood and 
the properties of the organized structures of the body. Sometimes this 
impairment is so profound as to actually suspend molecular changes and 
cause the death of the patient within the first forty-eight hours. If this 
result is not reached, and the disease is prolonged, there is developed a 
special inflammation of some part of the lymphatic system of glands, 
most frequently in the groin or upper part of the thighs, but may occur 
in any part of this system of glands, either in the internal or external 
parts of the body. 

Pathological Anatomy.- — In many cases of plague, death takes place 
so soon after the commencement of the disease, that the evidences of 
morbid changes of structure in any part of the body are very slight. 
The blood presents the same dark color and diminished coagulability as 
in typhus. When death has resulted at any time after the third day in 
the progress of the disease, in addition to the dark and uncoagulable con- 
dition of the blood, the spleen is pretty uniformly enlarged, softened and 
very dark color; the mesenteric glands a little enlarged, and presenting ec- 
chymosed spots. The latter are also often found in different parts of the 
mucous and serous membranes, and sometimes in the parenchyma of the 
more important organs. But the most constant, and apparently the most 
characteristic, anatomical changes are found in some part of the lymphatic 
glands. The enlarged and morbid condition of these glands is found in 
the inguinal regions, axilla, the upper part of the thighs, in the mediasti- 
num, along the larger bronchial tubes, in the neck, in the pelvis and in 
the abdomen just below the diaphragm. It is not often that ..the glands 
are found diseased in all these places in the same patient; but they are 
pretty uniformly found enlarged and increased in vascularity in one or 
more places, When laid open, the diseased glands present various ap- 
pearances, some being uniformly red, others white and granular, but all 
more or less softened, and some of them reduced to a pulpy or jelly-like 
consistence. I think the pathological condition of the lymphatic glands 
bears the same relation to the general fever in the plague, that the disease 
of the glands in the mucous membrane of the ilium and the mesentery 
does to the typhoid variety of general fever. 

Treatment. — Modern writers have given us no definite instructions in 
regard to the treatment of this form of fever. From the virulence of the 
exciting cause or causes, and the rapid impairment of the quality of the 
blood and the general properties of the tissues which result from their 



TREATMENT. 131 

action, it is evident that a large proportion of the cases will always ter- 
minate fatally before any treatment can develop sufficient influence to 
arrest the progress of the morbid action. And yet, both the symptoms 
during life and the changes revealed by examinations after death afford 
certain rational indications for our guidance in the selection and applica- 
tion of remedial agents. These are: first, to suspend as far as possible, the 
further action of the causes, either by removing the patient beyond their 
influence or by neutralizing their effects; second, to lessen the intensity 
of the febrile movement, and promote natural secretory action; and third, 
to prevent the deterioration of the blood and the destructive changes so 
constantly liable to occur in the lymphatic system of glands. To accom- 
plish the first you must secure thorough ventilation and cleanliness of the 
rooms occupied by the sick, and use such disinfectants as will most effect- 
ually destroy the noxious quality of the excretions and eliminations from 
the bodies of the patients. 

To lessen the rapid rise of temperature and promote more healthy 
eliminations from the skin and lungs during the first two or three days, 
frequent sponging of the whole surface with cool water, aided, if neces- 
sary, by the wet sheet and sprinkling once or twice in the day, constitute 
the safest and most efficient means that can be employed. For a general 
alterant to sustain the molecular changes throughout the system, and to 
lessen the morbid action in the lymphatic glandular system, I should have 
great confidence in the early and persistent use of iodine internally, in the 
form of aqueous solution, as in the following formula: 

^ Todinii, 0.5 grams, gr. viii 

Potassii Iodidi, 3.0 grams, gr. xlv 

Aquae Distillatae, 45.0 c. c. §iss. 

Mix, and take one cubic centimetre or fifteen minims every three or 
four hours, in a tablespoonful of sweetened water. 

In all other respects the details of treatment may be the same as in the 
more severe grades of typhus. 

Prophylaxis. — The chief prophylactic measures are, thorough ventila- 
tion, cleanliness, and a proper supply of good food and wholesome water, 
with isolation of the sick as far as practicable. 



LECTURE XVI. 

Relapsing Fever— Its History, Causes, Symptoms, Diagnosis, Prognosis— Special Pathology— Patho- 
logical Anatomy and Treatment. 

GENTLEMEN : — The acute general disease now familiarly known as 
Relapsing Fever, has undoubtedly prevailed at different times and in 
different countries from an early period of medical history, but until after 
the commencement of the present century it was regarded as a variety of 
typhus, and alluded to under various names, as typhus recurrens, febris 
recurrens, five-day fever, seven-day fever, bilious typhus, relapsing fever, 



132 RELAPSING FEVER. 

and mild yellow fever. The first description of it as a distinct form of 
fever which attracted attention, was that given by Mr. Rutty in his His- 
tory- of the diseases of Dublin, founded on an epidemic that prevailed in 
that city in 1739 ; and another epidemic was described by Dr. Barker, in 
1801. The disease prevailed in Edinburgh in 1817-18, and was accurately 
described by Dr. Christison and Dr. Welsh. It was still more accurately 
described by Dr. O'Brien and Dr. Graves in 1826. From 1812 to 1818 it 
prevailed still more extensively in Ireland, Scotland and England, and it 
was the descriptions given of the epidemics during this period by Drs. 
Mackenzie, Cormack and Craigie, that gave still more prominence to the 
idea of it as a distinct form of fever. An epidemic of the disease appeared 
in London in 1847, and was made a special subject of study by Sir Wil- 
liam Jenner who, in 1850, so clearly presented the points of differential 
diagnosis between it and the other forms of continued fever, that nearly 
all subsequent writers have assigned it an independent position among 
the idiopathic fevers.* Dummler ailudes to relapsing fever in connection 
with typhus in Upper Silesia in 1818 ; Engel had also made similar allu- 
sions in connection with an epidemic of typhus in Bukowina, in 1816 ; 
Griesinger still more particularly described it as prevailing in connection 
with what he called bilious typhoid and typhus in Cairo, and other places 
in Egypt, in 1850 ; and it prevailed to some extent in the armies of 
France, England and Russia, during the war between those nations in the 
Crimea. In 1863 it prevailed severely in Odessa, and in 1865, in St. 
Petersburg. In 1868 it appeared in decided epidemic form in Berlin and 
Breslau, and has reappeared from time to time in those cities, and other 
places in North Germany, until the present date. 

The first cases of relapsing fever recognized in this country occurred in 
a company of Irish immigrants who arrived in Philadelphia in June, 1814. 
Fifteen of their number were admitted into the Philadelphia Hospital, 
and the disease with which they were afflicted was recognized and de- 
scribed by Dr. Meredith Clymer as genuine relapsing fever. The disease 
was not propagated beyond the company of immigrants mentioned, and 
we have no authentic record of other cases until 1850-51, when fifteen 
cases were observed and recorded in the Buffalo City Hospital, by Dr. 
Austin Flint. The patients were all Irish immigrants, six of whom had 
arrived within the space of five weeks; six had lived in this country be- 
tween six and sixteen months; one four and one five years; while the term 
of residence of the remaining one is not given. It does not appear that 
they came from any one locality in the city, or that they had any particu- 
lar connection with each other. Two were admitted to the hospital in 
October, four in November, eight in December, and one in January. f 
It is stated by Dr. Lebert that some cases of relapsing fever were intro- 
duced by Irish immigrants into New York city in 1847. J And Dr. Aus- 
tin Flint alludes probably to the same cases when he says, " a few (cases) 
reported by Dr. A. Dubois, in 1848." § 

Dr. Dubois, however, simply reported some cases of severe " inflamma- 
tion of the eye, following typhus fever, as it appeared in the city of New 
York in 1847-48," in the Annalist for June, 1848. But neither in this paper 
nor in the communication on the same subject, furnished to the Commit- 
tee on Surgery of the American Medical Association, and published in 
the first volume of the Transactions of that body, p. 373, for 1847, can I 

* See Practice of Medicine, by George B. Wood, M. D.. &c, Vol. 1, note. p. 374, fifth edition.— 1858. 
t See Clinical Reports on Continued Fever, by Austin Flint, M. D. p. 369, 1852. 
t See Ziemssen's Cyclopcedia of Practical Med. Vol. I. p. 260, 

f >ee A Treatise on the Principles and Practice of Medicine, Fifth Ed., by A. Flint, M. D., &c, 
p. 982. 



CAUSES. 133 

find any adequate proof that the fever which preceded the cases of ophthal- 
mia reported, was any different from ordinary typhus. The first epidemic 
prevalance of relapsing fever, of which we have any account, commenced 
in the city of New York, in the last part of 18G9, and continued through 
1870 and the first part of 1871. The epidemic reached the climax of its 
prevalence in June and July, 1870; after which it rapidly declined. The 
whole number of cases reported to the New York Board of Health during 
the year 1870, was 2,121, of which 1,594 occurred during the first half of 
the year. During the same year the fever also appeared in epidemic form 
in Philadelphia, 517 cases having been admitted into the Philadelphia 
Hospital between April and November of that year. At the same time a 
few cases of the disease were observed in many of the towns near New 
York, but chiefly in the persons of working men who had come directly 
from the city.* During that year five cases came under my observation 
in this city, two of which were admitted into the Mercy Hospital. Sev- 
eral cases occurred in the practice of other physicians, but not sufficient 
to attract public attention or indicate the existence of an epidemic. Since 
1871, I have not learned of the prevalence of this form of fever in any 
part of our country. 

Causes. — From the foregoing statements in regard to the history and 
geographical distribution of relapsing fever, you cannot fail to notice how 
closely they correspond with that of typhus. It has not only prevailed in 
the same localities and among the same classes of people, but also at the 
same times and seasons; the two forms of fever being freely intermingled 
in the same epidemic. So far, therefore, as relates to favoring circum- 
stances or predisposing causes, it must be conceded that those of relaps- 
ing fever are the same as we have already discussed in relation to the 
typhoid, typhus, and the plague. It is claimed to be more contagious 
than typhus. That it is capable of being communicated from the sick to 
the well under certain circumstances, appears fully proved. It is neces- 
sary that the contact with the sick should be close, as in the case of 
nurses and attending physicians, or that the atmosphere surrounding the 
sick should be impure, either from overcrowding or want of ventilation. 
Under such circumstances many of those coming in contact with the sick, 
whether physicians, nurses, or visitors, contract the disease. But when 
there is no overcrowding of many patients together, and the air of the 
sick room is kept fresh and good, there is very little tendency to propa- 
gate the disease by contagion. Only those who handle the patients or 
their clothing, then, contract the disease, and even they often escape. Its 
contagiousness is, therefore, of the same character as that of typhus. In 
1873, Obermeier discovered in the blood of relapsing fever patients, dur- 
ing the febrile stages, what is described by Lebert as " exceedingly thin, 
thread-like, spiral fungi." Dr. Flint calls it a " spiral-shaped bacterium." 
It has been named by common consent Spirillum Obermeieri, and strongly 
resembles the spirochaete plicatilis seen by Colin in mucus from the 
mouth. Similar spiral-shaped bacteria have been discovered by Ehren- 
berg in water; by Billroth in the fluid from noma; and by Manassein in 
the contents of a cyst.j- 

The discovery of Obermeier has been confirmed by Lebert and his as- 
sistants, Weigert and Buchwald, who found the same spirillum in the 
blood of all the relapsing fever patients coming under their care in the 
hospital at Breslau, in 1873 anl 1874. 

* See Report on Relapsing Fever, by Stephen Smith, M. D., in the Annual Report of the Board 
of Health of New York, 1870-71, p. 456. 

fsee Principles and Practice of Medicine, by Austin Flint, M. D., etc., Fifth Edition, p. 9S4. 



134 RELAPSING FEVER. 

No one of the observers, however, has thus far discovered any of these 
minute paracites in the organs or structures of the body, or anywhere, ex- 
cept in the blood during the actual presence of the fever. They disap- 
pear quickly after the commencement of the intermission, re-appear in 
the relapse, and again quickly disappear with the final defervescence. 
All efforts to cultivate or propagate them have failed, yet Lebert confi- 
dently represents them as the essential cause of the fever.* Such a con- 
clusion, however, is premature, as there are no positive facts indicating 
whether they act as a cause or are merely an accompaniment of the gen- 
eral fever. On the contrary, if the spirillum discovered by Obermeier is 
identical with the spirochete of Ehrenburg and Cohn, it is by no means 
peculiar to the blood of relapsing fever patients, and it will require a 
much more extensive and varied series of observations than have yet been 
made, to afford a sufficient number and variety of facts to justify the an- 
nouncement of positive conclusions concerning the protomycetic origin of 
this variety of the fever. The disease, during an epidemic, attacks per- 
sons at all periods of life, but in larger proportion children under fifteen 
years, and adults between twenty and thirty years of age. Neither sex 
nor season of the year appear to exert any influence over the prevalence 
of the disease. The poor, destitute and overcrowded portions of the pop- 
ulation furnish most of the victims in every epidemic. So true is this, 
that in Ireland it is frequently called famine fever. The period of incu- 
bation is supposed to vary from three to nine days. One attack does not 
permanently destroy the susceptibility of the individual to one or more 
subsequent attacks. 

Symptoms. — An attack of relapsing fever commences abruptly with a 
well marked chill or cold stage, which is generally of short duration, and 
is followed immediately by active febrile excitement. The skin becomes 
hot, the face flushed, the tongue covered with a thin, white fur, the pulse 
frequent and compressible, usually from 100 to 110 per minute, but some- 
times reaching 130 before the end of the first twenty-four hours ; respira- 
tions accelerated in frequency, and temperature in the axilla from 39° C. 
(102 .5° F.) to 40° C. (104. 2 6 F.) ; very severe pains in the head, back and 
limbs, more especially in the muscles and joints of the extremities ; there 
is also much nausea and distress in the epigastrium, with frequent vomiting 
of matter tinged with the coloring matter of bile, and sometimes diar- 
rhoea, but more frequently moderate constipation. The quantity of urine 
is much diminished, redder than natural, sometimes, though rarely contains 
albumen, and still more rarely blood-corpuscles and hyaline casts. The 
active general febrile excitement thus established, usually continues with 
but little change in the assemblage of symptoms, from five to seven days, 
when it declines as rapidly as it was developed. During the whole of 
this period the patients are very restless, getting but short intervals of 
sleep, suffering severely from pains in the parts already mentioned, having 
occasionally epistaxis, and temporary sweating, but very rarely either de- 
lirium or stupor. The decline of the fever is generally marked by a copi- 
ous perspiration, during which the temperature returns nearly or quite to 
the natural standard, and the patient presents all the ordinary appear- 
ances of real convalescence. This state of apyrexia or intermission, usu- 
ally continues from three to seven days, when the patient is again attacked 
abruptly by a chill or chilliness, speedily followed by fever similar in all re- 
spects to the first attack, except in being a little less severe. It also con- 
tinues about the same length of time, namely, from five to seven days, and 
again terminates abruptly in a copious sweating. 

* See Cyclopaedia of the Practice of Medicine by Ziemssen, Vol. I, page 263. 



SYMPTOMS. 135 

Sometimes, though rarely, the crisis is marked by a temporary diar- 
rhoea, or diuresis instead of perspiration. The decline of the second feb- 
rile period is generally followed by permanent convalescence, but not al- 
ways. In a very smail proportion of the cases, after five or six days of 
intermission, a third period of fever supervenes, presenting the same char- 
acteristics as the second, and terminating in the same manner. Even a 
third relapse 1 or fourth period of pyrexia has been noticed by some practi- 
tioners ; and, on the other hand, a few cases have been observed which 
presented but a single febrile period of from five to seven days' duration, 
followed by permanent convalescence. You perceive by this description 
that the ordinary course of the disease, consisting of two active periods of 
fever, separated by a few days of intermission, usually occupies from two 
to three weeks, while the extremes may vary from a single febrile period 
of three or four days, to four pyretic periods, which, with the intervening 
intermissions, may extend the sickness to six or seven weeks. The con- 
valescence in all cases is attended by considerable muscular weakness and 
some degree of impoverishment of the blood, but it is seldom followed by 
an v important sequelae. A severe form of ophthalmia has been observed as 
a sequel of the fever in a limited number of cases.* In some of the more 
severe epidemics, many of the patients showed a moderate yellowness of 
the skin, which gave rise to the name of " mild yellow fever." 

In the few instances in which the disease has terminated fatally, the gas- 
tric symptoms have been unusually severe, the matter vomited presenting 
a dark coffee ground color, the secretion of urine being nearly or quite 
suppressed ; and in some instances petechial spots on the skin, and in 
others the nervous disturbances of uremic poisoning have preceded the 
final collapse. In some cases of only average severity, the sudden termi- 
nation of the febrile period in the intermission or the convalescence has 
caused the pulse to diminish in frequency, in four or five hours, from 130 
per minute to 54 ; and the temperature from 40.5° C. (105° F.) to 35° C. 
(95° B\). 

The depression below the natural standard of pulse and temperature in 
such cases proved to be of brief duration, and was attended by no bad 
results. 

Diagnosis. — The symptoms more specially characteristic of this vari- 
ety of fever, are the abruptness of its beginning; the rapid rise of temper- 
ature, the severity of the gastric symptoms; the violence of the pains in 
the muscles and joints; the sudden decline accompanied by copious 
sweating, and the equally sudden relapse after several days of complete 
intermission. Negatively, it is distinguished from the epidemic influenza, 
by the absence of catarrhal symptoms; from the dengue by the absence of 
the scarlet eruption and the remission of fever during the third and fourth 
days; and from typhoid and typhus by the absence of a prodromic or 
forming stage, and the dull expression of countenance, and later, the 
absence of either rose spots or maculas on the skin, and the entire absence 
of gurgling, abdominal tympanites, and muttering delirium. 

Prognosis. — Considering the severity of the symptoms, and their dura- 
tion, the prognosis is unusually favorable in this disease. In the majority 
of seasons when it has prevailed, the ratio of mortality has not exceeded 
two per cent, of the number attacked. Of one hundred and three cases 
admitted into the Bellevue Hospital in the winter of 1869-70, only two 
died. One of these died suddenly on the seventh day, supposed to be from 
syncope. The other died from uremic convulsions and coma, produced 

* See Transactions of American Medical Association, Vol. I, p. 373.— 1847. 



136 RELAPSING FEVER. 

by suppression of urine.* In some unsually severe epidemics the ratio of 
mortality has reached ten per cent. In most instances the fatal termina- 
tion has resulted from the supervention of local complications, such as 
pneumonia, acute nephritis, meningitis, etc. Lebert informs us that in an 
epidemic at Breslau, pneumonia was the principal complication, while 
during a severe prevalence of the disease in St. Petersburg, the principal 
dangerous complication was a haemorrhagic pachymeningitis. Fatty de- 
generation of the heart has been assigned as the cause of death in some 
cases. 

During the prevalence of the disease in Philadelphia in 1870, it at- 
tacked a considerable number of the colored population, and proved fatal 
in a much larger proportion of the cases than among the whites. When 
it attacks pregnant women it very generally induces an abortion or pre- 
mature labor. The foetus is usually born dead, but the mother recovers. 

Special Pathology. — It is evident from a careful study of the symp- 
toms presented by this disease, and the results as found on post mortem 
examinations, that the primary change in the properties of the tissues is 
neither one of simple exaltation or excitement, as in the febriculae, nor of 
direct depression, as in the typhoid and typhus ; but rather one of spe- 
cific character, consisting of an increase of the susceptibility, coupled with 
a moderate impairment of the vital affinity. The action of the special cause 
or causes of the disease in the directions just named, produces decided 
impairment of the molecular changes constituting nutrition, disintegration 
and secretion, accompanied by active disturbance of nervous sensibility. 
The latter is indicated by the severe pains felt by the patients in the 
head, back, and extremities, coupled with much restlessness, and func- 
tional disturbance of the stomach, instead of the dullness and indifference 
that characterizes the typhoid and typhus. The comparatively uniform 
and limited duration of the febrile symptoms, ending abruptly in critical 
evacuations, show the nature of the morbid impressions and actions to be 
decidedly that of irritation, with but little tendency to structural changes 
in any of the tissues, or to serious impairment of the constituents of the 
blood. 

Pathological Anatomy. — There are no pathological changes of struc- 
ture specially characteristic of relapsing fever. Careful, microscopic ex- 
aminations have discovered the same tendency to granular, fatty degener- 
ation in nearly all the important organs and structures, as is found after 
death from typhoid fever. Slight hemorrhagic exudations or infractions 
have been found in the brain, liver, spleen, and kidneys. The spleen 
is generally much enlarged, dark colored, and softened, being filled up with 
lymphoid elements, in which are large granular cells containing fat, and 
sometimes red blood corpuscles. More rarely, points of suppuration have 
been seen. The liver and kidneys are also generally enlarged and their 
texture changed in the same direction as that of the spleen, but less in 
degree. In a majority of cases examined, the muscular structure of the 
heart, and the striated muscular structures in other parts of the body, 
were found in various stages of fatty degeneration. In a small proportion 
of the cases ecchymoses were seen in the mucous membrane of the stom- 
ach, the pleura and pericardium, and petechial spots on the skin. A limi- 
ted amount of inflammation has generally been found in the mucous mem- 
brane of the ilium and colon, with enlargement of some of the solitary 
glands. The only differences between the changes I have now described 
and those in typhoid fever, consist in traces of more active inflammatory 

* See Principles and Practice of Medicine, by Austin Flint, M. D. etc. Fifth Edi. p. 990. 



TREATMENT. 137 

action in the kidneys and spleen, and a greater number of points of hem- 
orrhagic exudation in other parts. This is explained in part by the fact 
that in relapsing fever the susceptibility of the tissues is less impaired, 
and in part by the further fact that the disease seldom terminates fatally 
except by the supervention of some local inflammatory complication, such 
as nephritis, pneumonia, meningitis, etc. Dr. Lebert states that while the 
disease was prevailing in Breslau, numerous post mortem examinations 
were made, and though diligently searched for, no traces of the Spirillum 
Obermeieri were found in any of the structures of the body. The blood 
was uniformly found dark in color, and either fluid or less coagulable than 
natural. The microscope showed an increase in the proportion of white 
corpuscles, a greater number of minute granular bodies, and occasionally a 
large fatty cell; none of which, however, are peculiar to the blood in this 
disease. 

Treatment. — The indications for treatment are, first, to suspend as far as 
possible the further influence of both predisposing and exciting causes; 
second, to relieve the suffering of the patient by palliating the more dis- 
tressing symptoms; third, to prevent the development of important local 
complications; and fourth, to sustain the strength and general nutritive 
processes until convalescence is well established. The predisposing causes 
are best removed by securing for the patient fresh air, cleanliness, rest, and 
suitable nourishment. If there is a specific exciting cause acting through 
the blood upon the properties and functions of the system, whether it 
consist of the Spirilli of Obermeier, the Spirochete of Ehrenberg and Cohn, 
or some other infectious material, it would afford a rational indication for 
the early and persistent use of some antiseptic or parasiticide. Keeping in 
mind the second indication I have mentioned, namely, to lessen the se- 
verity of the patient's suffering, which is chiefly from the intense pains in 
the head, back, and extremities, with epigastric distress and vomiting, we 
should select such antiseptics as will aid most in alleviating these symp- 
toms at the same time that they tend to destroy the specific infection in 
the blood. For accomplishing both these purposes there are probably none 
more efficient than the carbolic and salicylic acids. 

The first of these I used in combination with gelsemium and camphor- 
ated tincture of opium, in the treatment of the few cases that came un- 
der my care in 1870, and found it quite efficient in arresting the vomiting 
and lessening the pains and restlessness. From the known efficacy of 
salicylic acid in relieving the intense pains of acute rheumatic fever and 
its efficiency as a parasiticide, I should expect great benefit from its 
prompt use in the early stage of the relapsing fever, if the stomach would 
retain it. During the prevalence of the disease in Berlin in 1878-79, 
Dr. Riess reports having used the salicylate of sodium, with excellent re- 
sults. In the early stage of the disease the salicylate of sodium should 
be given in 0.66 gram (gr. x.) doses dissolved in water, and repeated 
every two or three hours until the severe pains and restlessness abate, 
after which it may be continued at longer intervals until the intermission 
supervenes, unless as the crisis approaches between the fifth and seventh 
days, the pulse becomes weak and slow, the face pale, with a sense of 
weakness or weariness. Should these symptoms supervene, the salicy- 
late should be omitted, and in its place 0.13 grams (gr. ii.) of quinine 
may be given every four hours, and alternating with it a powder contain- 
ing 0.33 grams (gr. v.) of Dover's powder with 0.13 grams (gr. ii.) of 
pulverized gum camphor. If, at the beginning, the nausea and vomiting 
is sufficient to interfere with the retention of the salicylate of sodium, 



138 RELAPSING FEVER. 

they may be first allayed by giving during the first twelve to twenty-four 
hours the carbolic acid combined as in the following formula: 

fy Acidi Carbolici, 0.5 grams gr. viii. 

Glycerinae, 15.0 c. c. 3iv. 

Tinctura? Gelsemii, 15.0 " 3iv. 

Tincture Opii Camphoratae, 60.0 " §ii. 

Aquaa, 60.0 " JiL 

Mix, and give 4 cubic centimeters (fl. 3i.), or an ordinary teaspoonful 
every two or three hours, until the vomiting ceases. This may be aided 
by the application of cloths wet in cold water to the head, and mustard 
sinapisms to the dorsal part of the spine and to the epigastrium. When- 
ever the skin is hot and dry, frequent sponging of the surface with cool 
water, will be both grateful to the patient and efficiently antipyretic. To 
prevent local convocations, daily attention should be given to the quan- 
tity and quality of the urine, and if it becomes very scanty, either with or 
without the presence of albumen, digitalis may be given in connection with 
the acetate of potassium. If diarrhoea or dysentery supervene, they 
should be checked by the same remedies that I recommended for restrain- 
ing excessive intestinal evacuations in typhoid fever. As soon as the in- 
termission supervenes, the patient should have as much nutritious food as 
will be readily digested ; avoid all fatiguing exercise and take fro m 
0.66 to 1.00, grams (gr. x. to xv.) of the sulphite or hyposulphite of sodium 
dissolved in mint water, before each regular meal-time, and at bed-time, and 
a pill containing citrate of iron and quinine, each 0.13 grams (gr. ii.), af- 
ter each meal-time. By the action of the salicylate of sodium during the 
febrile stage, and the sulphite during the intermission, I should expect the 
relapse to be entirely prevented, or its severity greatly lessened. If, at the 
usual time, however, the febrile stage returns, it must be treated on the 
same principles and by the same means, as in the first stage, though it is not 
generally necessary to pursue the treatment as actively as at first. The 
same vigilance must be exercised in regard to the checking of local com- 
plications, and more care must be taken to see that the patient is supplied 
with proper nourishment. When convalescence finally comes, the patient 
should continue to take small doses of quinine and iron, plain but nutri- 
tious food, and be very cautious about taking much exercise either of 
body or mind, until the strength is well restored. There are no sequela? 
peculiar to relapsing fever. 

Prophylaxis. — The best means for preventing the spread of the dis- 
ease, are, to isolate the sick as far as practicable, efficiently enforce whole- 
some sanitary measures, and secure for the masses of the people a proper 
supply of good food. 



YELLOW i'EVER. 139 



LECTURE XVII. 

Yellow Fever— Its History, Causes, Symptoms, Diagnosis, Prognosis, Pathological Anatomy, 
Special Pathology, and Treatment, Prophylaxis. 

GENTLEMEN: — I now invite your attention to a disease, which, from its 
frequent recurrence in epidemic form, the high ratio of mortality 
resulting from it, and its serious interference with important commercial 
interests, has attracted much attention in this country, not only from phy- 
sicians but from sanitarians and the public generally. I refer to Yellow 
Fever, or Typhus Icterodes of the ancients. As the home of the plague 
was formerly traced to Egypt and the countries bordering on the eastern 
part of the Mediterranean Sea, typhus and relapsing fever to the British 
Islands and the countries bordering on the Baltic, so the yellow fever is 
traced still more definitely to a home or permanent habitat in the Antilles 
or West Indian, and other islands in the tropical part of the Atlantic Ocean 
and Gulf of Mexico, and the northwestern part of the coast of Africa. 
Within the limits just named it prevails to some extent every year; some- 
times very mildly and in other seasons with great severity. At irregular 
periods, varying from three to ten years, it breaks over these apparently 
natural boundaries, and appears epidemically in the principal cities and 
seaport towns bordering on the Gulf of Mexico, in the south and south- 
e -stern part of this country, in the northeastern portion of South America, 
as far south as Montevideo and Buenos Ay res, and along the northwestern 
coast of ^Africa, and the southwestern coast of Europe, to the borders of 
Spain, Portugal and France. In our country, it has at times extended 
inland, chiefly along the rivers and lines of commerce, as far northward as 
the Ohio River, and along the Atlantic coast northward to Norfolk and 
Portsmouth in Virginia, and very rarely to Philadelphia and New York. 
Within the tropical part of the Atlantic Ocean it often makes its appear- 
ance on shipboard as well as on land. It has not been known to prevail 
to any extent on any of the islands in, or coasts bordering on, the Pacific 
Ocean. You perceive that the home of the disease is in warm climates, 
but why it should habitually prevail on the islands, ships and seaport towns 
in the tropical part of the Atlantic, and not in corresponding parts of the 
Pacific Ocean, is not easy to explain. When the disease extends beyond 
its ordinarv boundaries in an epidemic form, it is always during the warm 
season of the year. 

Dr. H. Hartshorne states that the first appearance of yellow fever in any 
part of our country, of which we have any record, was at New York in 
1G68; its first appearance in Philadelphia, was in 1695; in Mobile in 1705; 
and in New Orleans in 1769. Since the last date mentioned, the most se- 
vere epidemics have been in 1819, '47, '53, '54, '55, '58, '67, and '78. From 
1695 to 1822, the disease several times prevailed severely in New York 
and Philadelphia, but since the latter date it has not prevailed sufficiently 
to merit the name of an epidemic north of Portsmouth and Norfolk on the 
Atlantic coast, and not north of the line of the Ohio river, and St. Louis 
in the interior, or valley of the Mississippi. It prevailed to a very limited 
extent on a part of the coast of Staten Island, at the entrance of New 
York harbcr, in the summer of 1847. Perhaps the most extensive epi- 
demic of the disease that has ever occurred in this country, was that of 1878. 



140 YELLOW FEVER. 

Causes of Yellow Fever. — The circumstances that favor the prevalence 
of yellow fever are : a protracted high temperature, giving a mean above 
22° C. (72° F.); proximity to the waters of the Atlantic ocean, or the 
gulfs, rivers, and bays communicating with it, between the parallels of 
latitude of 45° north and 35° south; and low altitudes, or such as approx- 
imate to the level of the ocean. In regard to the first of these favoring 
circumstances, or predisposing causes, it is necessary to remind you that 
it is not the mere high temperature of one or two days, but of several 
weeks, that appears to be necessary as one of the conditions under which 
the disease may become epidemic. Hence it seldom commences to attract 
public attention in New Orleans, and other places bordering on the Gulf 
of Mexico, until a little past the climax of summer heat; or, in other words, 
not until the last half of July, and sometimes not until in August. When 
it has fairly commenced, it generally continues until so far in Autumn 
that the atmospheric temperature falls below the freezing point, after 
which new cases become infrequent, and the disease soon disappears from 
the community. Isolated or sporadic cases may occur earlier in the season ; 
or cases may be introduced from on board ships from some of the West 
India Islands, but there has been no development into an epidemic preva- 
lence until the summer temperature has been well advanced. Previous 
to the epidemics of 1867 and 1878, '79, the disease had never manifested 
much tendency to extend into the interior, remote from the sea coast, ex- 
cept along rivers and water courses occupied by commerce, and opening 
into the sea within the yellow fever zone. But in these two later epi- 
demics, it extended over a large part of the interior of the states border- 
ing on the Gulf, and northward through Tennessee and parts of Kentucky 
and Missouri. In regard to the influence of elevation, I think the highest 
point on which the disease has prevailed in this country, was at Galli- 
opolis, a little more than 600 feet above the ocean. But within the trop- 
ics the disease has been reported at New Castle, Jamaica, at an elevation 
of 4,000 feet, and in some parts of Mexico at 3,243.* 

During the last few years, Dr. W. Huston Ford, of St. Louis, has pub- 
lished the results of observations concerning the relations of temperature 
to the prevalence of yellow fever. He has been enabled to compare the 
meteorological and mortuary records of Charleston, South Carolina, 
through a period of thirty-eight years, and of ten other southern cities for 
a period of five years. Of the thirty-eight years included in the records 
in Charleston, seventeen were characterized by more or less prevalence of 
yellow fever. In six of these seventeen years the disease assumed a se- 
vere epidemic form ; in six, mildly epidemic, and in five, only a few spor- 
adic cases occurred. Only twice during the whole period did the disease 
prevail in decided or severe epidemic form two years in succession. In 
nearly all instances only sporadic or scattering cases occurred the sum- 
mer succeeding a severe epidemic. The commencement of the disease 
was generally in August, and its prevalence was limited to the months of 
August, September and October. On comparing the meteorological with 
the mortuary records for the whole period of thirty-eight years, Dr. Ford 
found that the years in which the yellow fever was epidemic were the 
same in which the summer heat rose to the highest mean for the three 
months just named in each year. The six years of severe epidemic prev- 
alence were also the six years giving the maximum mean temperature of 
the summer months. The six years of slight epidemics ranked next in the 
mean temperature of the same months. 

* See A System of Medicine, by J. Russell Reynolds, M. D., etc. Vol. 1, p. 284, Amr. Edition, 1S79. 



CAUSES OF THE DISEASE. 141 

The five years of sporadic cases gave a mean temperature for summer 
and autumn less than those in which the disease was moderately epidemic. 
In the remaining twenty years in which there was no prevalence of the 
yellow lever, the mean temperature of the summer months was at the 
minimum: the highest of any of these years being lower than the lowest 
of those in which the disease prevailed. The only exception to this rule 
was in 183(3, when the mean temperature of the months of July, August, 
September. and October, was as high as the years of most severe epidemic 
prevalence of yellow fever, and in that year the city was scourged by a 
severe epidemic of cholera, that appeared to supercede the yellow fever. 
Dr. Ford has analysed and compared these statistics of Charleston in the 
most varied and philosophical manner, but always arriving at the same 
result, namely, that the seasons of yellow fever epidemics are identical 
with those of highest summer temperature. His comparison of meteor- 
ological and mortuary statistics in the other ten cities situated on the Gulf 
of Mexico and along the Mississippi River, as far north as St. Louis and 
Louisville, is only for a period of five years, including 1874-5-6-7-8. 
But they lead to precisely the same conclusions. 

Thus the summers of 1873-4, were a little above the average mean for 
a series of ten years, and there were moderate epidemics of yellow fever 
in several of the cities on the lower Mississippi and the Gulf. The sum- 
mers of 1875-6-7, were decidedly below the mean temperature for a series 
of ten consecutive years, and there were no epidemics of the fever in any 
of the cities under consideration. The mean temperature for July, August, 
September and October, was the lowest in 1875, from which an annual in- 
crease was presented in 1876 and 1877, culminating in the extraordinary 
summer temperature of 1878, and the equally extraordinary epidemic prev- 
alence of the disease. The mean temperature of the summer of 1879, falls 
below that of 1878, yet is decidedly above the average for a series of years, 
especially in the middle and lower part of the Mississippi valley. And 
true to the law already deduced, the yellow fever re-appeared fairly epi- 
demic in Memphis and its vicinity, and sporadically in New Orleans and 
a few other places. These eminently philosophical deductions of Dr. Ford, 
are corroborated by a great variety of other facts; and are sufficient to 
show a necessary connection between unusual high summer temperature 
and the appearance of yellow fever epidemics. If the investigations re- 
lated only to the years 1878 and 1879, or to any other one or two years, 1 
the co-existence of a high, mean summer temperature and an epidemic 
prevalence of the fever, might be regarded as merely accidental; but when 
the statistics cover a perioi of thirty or forty consecutive years, as in the 
case of Charleston, and the same co-existence is found uniform throughout, 
the presumption of accidental coincidence ceases, and the deduction as- 
sumes the importance of a fixed law. The same series of investigations 
and statistical comparisons also establish the important fact, that the fever 
never assumes an epidemic character until the high summer temperature 
has progressed two months, namely, through the months of June and July; 
the favorite month for its epidemic ravages to commence in our country, 
being August. And in the few instances of its commencing to prevail 
epidemically in July, it is found that the high summer heat had com- 
menced in May. Such was the case in Memphis, in the summer of 1879. 
In the temperate zone the sun reaches a position relative to the earth, 
which gives to its rays most directness and power to impart the greatest 
amount of heat to the earth's surface, about the 21st of June. At the 
same time, the days become the longest compared with the nights, and 
consequently, more heat is absorbed each day by the earth than is radi- 



142 YELLOW FEVER. 

ated into the air during the night; and hence there is a steadily increas- 
ing temperature of the earth's surface through June, July and August, 
while that of the atmosphere may be much more fluctuating. Oftentimes, 
even here in Chicago, the mercury rises higher for a few hours in the mid- 
dle of some days during the third week in June, than in any other days of the 
year, but the nights are yet cool, and no visible disturbances of health re- 
sult from such temporary high temperature. So also many instances have 
occurred where ships having yellow fever on board, have arrived in New 
Orleans and other Gulf or Atlantic ports, during the months of May and 
June, and even here and there a sporadic case has occurred in those cities, 
independent of any known importation, during those months; yet no gen- 
eral or epidemic development has appeared, until the latter part of July 
or in August, and in many instances, not until early in September. These 
facts show that it is not merely high temperature, but such temperature 
continued until the surface of the earth reaches a degree of heat and mois- 
ture most favorable for rapid decomposition of organic matter, and the sus- 
pension of the products of such decomposition, with aqueous vapor in the 
atmosphere, that we get the exact meteorological condition necessary for 
originating or sustaining an epidemic of yellow fever. But even when 
the temperature is sufficiently high and long continued, with a moisture 
most favorable for fermentation or decomposition of organic matter, yet 
no epidemic yellow fever will be developed, unless the particular kind of 
organic matter required be present to undergo such change, in sufficient 
quantity to impregnate the atmosphere to a considerable extent. Just 
what the deleterious material is that is engendered and diffused in the at- 
mosphere as the pabulum lor supporting yellow fever, is not yet known. 
Neither is it iully known what kind of fermentative or decomposible 
organic matter is necessary to furnish the pabulum on which the heat and 
moisture are to act. Yet all the facts connected with the origin and prog- 
ress of the yellow fever during the years 1878-9 point unmistakably 
to local atmospheric and topographical conditions as exerting a controll- 
ing influence over the spread or continuance of the disease, whether its 
supposed essential cause was imported or not. For instance, in the sum- 
mer of 1878, the disease assumed an epidemic form in New Orleans dur- 
ing the month of July, and prevailed nearly a month before any cases 
were recognized in Memphis, although there was constant communication 
between the two cities, both by river and railroad. And at a still later 
period the disease made its appearance in many smaller places, more or 
less distant from each other, so nearly simultaneous as to preclude the 
possibility that it had been communicated from one to another. 

Again, in the year 1879, as is well known, the disease commenced in 
Memphis, and prevailed severely before it had appeared in New Orleans, 
or any other place bordering on the Gulf. More than half the population 
speedily abandoned the city, scattering themselves widely over the more 
northern parts of the country; many hundred more went into camps on 
well chosen ground only twenty or thirty miles distant from the city; while 
the local board of health, aided by the State and national health organiza- 
tions, not only established and enforced the most rigid quarantine, but 
waged an unceasing warfare upon the disease in the city by isolation and 
disinfection, using almost unlimited quantities of the best antiseptic and 
disinfecting remedies known; and yet the epidemic continued the even 
tenor of its way in the city, and after five weeks made its appearance in a 
score or more of smaller places in different directions from Memphis. 
But the moment a severe frost made its appearance, reducing the temper- 
ature of the atmosphere a little below 0° C, or 32° F., the disease, which 



CAUSES OF YELLOW FEVER. 143 

for nearly three months had bid defiance to hundreds of tons of disinfect- 
ants ami any number of quarantines, even when aided by shot-guns, dis- 
appeared as if by magic. If we put the facts recently developed in re- 
gard to the necessary influence of continuous high temperature in origi- 
nating an epidemic of yellow fever, with the long known fact that a low 
temperature invariably extinguishes it, we have proof amounting to dem- 
onstration that the propositions already stated in relation to the several 
conditions that must co-exist in any given locality to allow the develop- 
ment of an epidemic of this disease, are correct. 

Without entering further into details in reference to the etiology 
of yellow fever, I will simply state that the contagium vivum theory, 
which assumes the essential cause of the disease to be an organic germ, 
capable of self propagation, and without the introduction of which from 
some prior case, no combination of circumstances can produce the dis- 
ease, is purely hypothetical and unsupported by any basis of ascertained 
facts. No organic germs peculiar to this disease have been found either 
in the blood, secretions, or tissues of yellow fever patients, though dili- 
gently sought for by many of the most competent microscopic investiga- 
tors, both in this country and Europe.* 

The well known fact that sporadic cases of yellow fever oocur in the 
West Indies and in New Orleans almost every summer, and that cases are 
brought on ships to more northern parts often, without causing any spread 
of the disease, show that if there is a fever genn, it certainly requires 
some peculiar local condition of the atmosphere for its propagation. An- 
other fact still more difficult to explain on the germ theory, is, that the 
disease very rarely prevails, as an epidemic, more than one or two years in 
succession in the same place. The same general series of facts bear still 
stronger against the doctrine of personal contagion. For a full and in- 
teresting discussion of the whole subject of the etiology of yellow fever, 
however, I must refer you to the very complete work of Dr. R. LaRoche, 
of Philadelphia, in two full sized octavo volumes, published in 1855. They 
constitute the most complete treatise on this disease in our language. Ba- 
fore leaving- this part of our subject, it is proper to remind you that many 
of those who have had ample opportunities for the personal study of yel- 
low fever, and who have been eminently qualified to judge correctly, hive 
regarded it as simply a modified form of the ordinary endemic malarious 
fever of the southern States. Thus Dr. Benj. Rush regarded the disease 
as it prevailed in Philadelphia during his day, as " nothing but a high 
grade of bilious fever;" and Dr. E. D. Fenner, of New Orleans, who in- 
vestigated with great care the origin and progress of no less than twelve 
epidemics in that city, says : " Our position is, that yellow fever is only 
one of the forms of endemic fever (malarious, if you will), which derives 
its characteristic features from the locality and attendant circumstances 
where it prevails."! 

Persons who have suffered from one attack of the fever, rarely become 
susceptible to subsequent attacks, although there are many exceptions to 
this rule. It attacks persons at all periods of life, yet the highest ratio 
both in numbers attacked and in fatality, is during the period of vigor- 
ous adult life, between 20 and 40 years of age. Sex appears to exert but 

* See Pathology and Treatment of yellow fever, with some remarks on the nature of its cause and 
its prevention, by H. D. Schmidt, M. 1)., of New OrLeans, La., in the Chicago Medical Journal and 
Examiner for October, 1881, p. 364. 

The Microphytes which have been found in the b'ood and their relations to disease, by Timothy 
Richard Lewis, M. D., etc., in the Quarterly Journal of Microscopical Science, for July, J879. 

The Microscopic Germ-Theory of Disease, bv H. Charlton Bastian, M. D., m Monthly Microscopi- 
cal Journal, August. 1875. 

fSee Transactions of the American Medical Associa ion, Vol. VII, p. 536, 1854. Repo:t on Epi- 
demics of Louisiana. 



141 YELLOW FEVER. 

littlo influence. The colored population have generally suffered much 
less during yellow fever epidemics than the white. Long residence or 
full acclimation has a very marked effect in diminishing the susceptibility 
to the disease, while but few of those who have recently come within the 
yellow fever zone, escape an attack during the prevalence of an epidemic. 

Symptoms. — The symptoms of yellow fever vary very much in their 
severity, in different cases and in different epidemics. There is generally a 
forming or prodromic stage of from one to three days duration, character- 
ized by a sense of weakness or indisposition to mental or physical activ- 
ity; some aching in the head, back, and limbs; with alternate feelings of 
heat and cold. These are followed by a more distinct chill, though of 
short duration, and active febrile reaction, giving to the face a deep suf- 
fused redness; a red and watery appearance of the eves; a hot and drv 
skin, the temperature rising rapidly to 39° or 40° C. (102.5° or 104.2° Fi) 
and sometimes to 43 d C. (110° F.); pulse from 90 to 100 per minute, and 
moderately full; tongue covered with a white or yellowish white fur, and 
moist; severe pains in the frontal region of the head and lumbar part of 
the spine, with general restlessness; much distress and tenderness in the 
epigastrium; considerable thirst, and in many cases frequent and severe 
vomiting, with more or less constipation of the bowels. The urine is 
scanty and high colored; and though the mind is generally clear, in many 
of the more severe cases, delirium is an early and prominent symptom. 
The group of active pyretic symptoms I have now enumerated, are all 
well developed if not at their climax before the end of the first twenty- 
four hours after the initial chill, and they continue with but little change 
in their character from two to five days, when they begin rapidly to de- 
cline, and in a few hours the patient is in a state of apyrexia, and so quiet 
and comfortable as to present almost all the features of an actual conva- 
lesence. And in the mildest class of cases there is no renewal of un- 
pleasant symptoms, and the convalesence is complete. In far the greater 
number of cases however, this intermission or " period oi calm " is only 
transient, lasting from six to twenty-four hours, when febrile symptoms 
return, in some cases in a much less active form than during the first par- 
oxysm, and after a mild course of from one to two weeks, ending in recov- 
ery; and in many others in a form so severe as to prove speedily fatal. 

It is generally during the intermission, and the subsequent renewal of 
febrile symptoms, that the skin begins to present the peculiar yellow hue 
which has given the name to the disease. In all the more severe cases 
the intermission is speedily followed by a soft, compressible, or gaseous 
pulse, either very frequent or preternaturally slow, sometimes falling to 
40 per minute, or even slower; the skin cool; the mind dull, wandering 
and incoherent; the urine very scanty and albuminous, or suppressed; 
and frequent vomiting, sometimes of a thin, white, and sour fluid, but 
much more frequently the matter vomited is thin, copious, and dark- 
brown, from the presence of flakes of a black coffee-ground appearance, 
consisting of altered blood corpuscles, and sometimes it is real, unaltered 
blood. In bad cases the skin becomes hourly more yellow; the eyes re- 
taining their redness, gives a peculiarity of expression highly character- 
istic of this disease; the pulse becomes weaker and more irregular; the 
vomiting more copious, being more like regurgitation than ordinary vom- 
iting; the discharges from the bowels dark-brown, sometimes thick and 
black, like tar, and at other times much like the dark coffee-ground mate- 
rial ejected by vomiting; blood not unfrequently oozes from the nose, 
gums, ears, fingers, kindeys, uterus, and into the skin, causing petechial 
spots or vibices, especially over the posterior part of the trunk of the body 



SYMPTOMS AND DIAGNOSIS. 145 

and extremities; complete collapse and death soon follows. Sometimes 
the death is preceded by entire suppression of urine, convulsions and 
coma, and in other cases the mind remains clear or free from derange- 
ment until the end. The entire group of symptoms I have thus stated as 
following the brief period of calm on the subsidence of the first run of 
active fever, may develop so rapidly as to cause death in the first twenty- 
four hours, or this result may not be reached until the end of the fourth 
or fifth day. And in a few instances, even after well-marked black vom- 
it, recoveries have taken place. In cases of less severity than those 
I have just described, the calm or remission is followed by the re-estab- 
lishment of fever, more resembling the typhoid in its grade and general 
features, which may continue from one to two weeks, and generally ends 
in convalescence. During the more severe epidemics, a few cases are 
usually met with in which the attack is sudden, and the morbid actions 
established in the blood and tissues so intense, that life is destroyed in 
from twenty-four to forty-eight hours. On the other hand, in the absence 
of special epidemic influence, the disease as it prevails endemically in the 
West Indies and sporadically in New Orleans, often runs a very mild 
course of from five to seven days, and ends in permanent convalescence. 
During seasons of epidemic prevalence, however, nearly all the cases pre- 
sent a well-marked active febrile paroxysm, continuing from three to seven 
days, a brief period of calm or intermission, and a renewal of febrile 
symptoms of greater or less severity, which may continue from a single 
day to two weeks. Most writers describe this order of phenomena as 
three stages of the disease; the first, a protracted paroxysm of active 
fever; the second, a brief stage of apyrexia or intermission; and the third, 
a period of secondary fever. Dr. Austin Flint and some others, prefer to 
regard the disease as consisting in a single protracted paroxysm of fever, 
and the periods of intermission and secondary fever as sequelae. 

Diagnosis. — The chief diagnostic symptoms in the early stage, are sud- 
denness of access, unusual redness of the eyes, severity of pains in the 
head, back and limbs, epigastric tenderness, and in many cases, active 
vomiting. The continuance of these symptoms from three to five days, 
ending rather suddenly in an intermission, accompanied by the develop- 
ment of yellowness of the skin, and such intermission followed in a few 
hours, by a renewal of fever with increased yellowness, with or without 
the vomiting of dark coffee-ground material, renders the diagnosis reason- 
ably certain. If to these symptoms are added, hemorrhages from the 
bowels, nose, mouth, and petechias, or hemorrhagic spots on the surface, with 
scanty and albuminous urine, the diagnosis is complete. You will see by 
these statements, that when a well-marked case of yellow fever is attended 
through its successive stages to the end, there is no difficulty in distin- 
guishing it from all other febrile affections. 

But in the very mild cases that terminate in convalescence, at the end. 
of the first febrile stage, there are no symptoms so distinctive or specially 
characteristic, as to enable the practitioner to differentiate them with cer- 
tainty, from cases of febricula on the one hand, or of mild remittents on 
the other. And in the early stage of cases of ordinary severity, there are 
no symptons except such as may be occasionally seen in the early exacer- 
bations of intermittent and remittent fevers. So true is this, that the most 
intelligent and experienced physicians in those southern cities most subject 
to the prevalence of yellow fever, differ in opinion about the diagnosis of 
the first few cases that occur at the commencement of every epidemic* 

*The late Dr. E. D. Fenner, of New Orleans, writes in regard to this subject, as follows: " The 
general impression derived frcm reading descriptions of jellow fever is, that.it is a violent fever 

10 



146 YELLOW FEVER. 

Dr. Aitken and some other eminent English writers, endeavor to make 
a distinction between the "true yellow fever," which they claim to be 
specific and propagated by personal contagion, and "a malarious form of 
yellow fever," which is allied to the ordinary periodical fevers. They ac- 
knowledge that yellowness of the skin, black vomit and other hemorrhages 
occur in both, and that the only reliable distinction is the communicabil- 
ity of the true or specific disease, from person to person, and its occur- 
rence in the same individual but once.* 

Judged by these tests, most of the important epidemics that have ap- 
peared in this country, would have to be classed as false or malarious yel- 
low fever. I think the distinction is not sustained by a sufficient number 
of accurately observed facts, and cannot be maintained at the bedside of 
the sick. 

Prognosis. — The yellow fever as it occurs endemically within the prop- 
er yellow fever zone, is often a mild, febrile disease and attended by a very 
small ratio of mortality. In its epidemic form, however, it is always at- 
tended by a high ratio of deaths; and yet the fatality accompanying one 
epidemic has differed much from that of others; and the same epidem : c 
has proved much more severe in some localities than in others, and gen- 
erally more fatal at the beginning and during increase, than during its 
decline. Dr. LaRoche estimates the average mortality of the disease in 
its epidemic form to be 1 in 2.32. The highest ratio that I have seen 
reported was 75 per centum. You must remember, however, that the fa- 
tality as stated by Dr. LaRoche and most other writers, is based mostly 
upon official reports from hospitals, boards of health, etc., and do not cor- 
rectly indicate the ratio of mortality in the private practice of intelligent 
and efficient physicians. For instance, in the severe epidemic which pre- 
vailed in New Orleans in the summer of 1853, there were reported from 
official sources 15,263 cases, of which 5,054 proved fatal, being 33.11 per 
centum; while Dr. Fenner tells us that of 127 cases occurring in his pri- 
vate practice during the same epidemic, only 7.87 per centum died, or a 
little more than 1 in 13. 

A part of this difference is attributable to the fact, that the cases treated 
in their own homes by their regular family physician, are generally seen 
earlier and the whole treatment conducted under more favorable circum- 
stances, than those taken to hospitals or placed in charge of official organ- 
izations. 

The symptoms that are regarded as pointing more directly towards a 
fatal result are, the black vomit and other severe hemorrhages, suppressed 
or scanty and highly albuminous urine, convulsions, and coma. The two 
last indicate the presence of uremic poisoning. Most writers represent the 
black vomit alone as a certain forerunner of death. But such is not 
always the case, although it is an exceedingly unfavorable symptom. In 
the epidemic of 1853 in New Orleans, according to Dr. Fenner's report, 

of a single paroxysm, lasting about seventy two hours, and presenting strongly marked characteris- 
tic symptoms, by which it may readiiy be distinguished from all other types of fever. I have not 
found it so ; nor have I yet found the man who could always say correctly whether a case, ex- 
amined per se, was yellow fever or not. I have already shown what differences of opinion were ex- 
pressed aboutthe first cases that appeared this year (1853), and have only to add that the same thing 
occurs here every year. The truth is, yellow fever is so closely allied to remittent and intermittent 
fever, that no uniform and reliable distinction can be drawn between them in the early stages, 
and the only way we get at the fact that yellow fever is prevailing, is by observing the final results, 
whether in death or convalescence ; and the former is by far the most conclusive of the two. Even 
in such an epidemic as this, thousands of cases occurred which no one would have thought of call- 
ing yellow fever, if it had not been generally known that many of the same character and appear- 
ance had terminated in fatal black vomit." — See report on the Epidemics of Louisiana, etc., for 
1853, by E. D. Fenner, M, D., in the transactions of the American Medical Association, Vol. 7, 1854, 
p. 466. 

*8ee the Science and Practice of Medicine, by Wm. Aitken, M. D., etc., Third Amer. Edition, pp. 
565-6. 



PATHOLOGICAL ANATOMY. 147 

to which I have already several times alluded, about seven per centum of 
the well marked cases of black vomit recovered. And he enumerates no 
less than thirty-eight similar cases of recovery in the private practice of 
six or seven well known practitioners in that city. The prognosis in all 
cases of 3'ellow fever must be given with caution, as there is no other 
general acute disease so deceptive, or subject to such sudden and unex- 
pected changes of an unfavorable character. 

The intemperate, or those who use freely alcoholic liquors, give a very 
high ratio of mortality when attacked with this disease.* 

Pathological Anatomy. — The peculiar yellow color presented by the 
skin in most fatal cases, is also seen on making post mortem examinations, 
staining all the membranous structures in some degree. Slight serous 
effusions have been found in some cases in the membranes of the brain, 
the pericardium and pleura, and more or less hypostatic congestion of por- 
tions of the lungs. But no pathological or structural changes, peculiar to 
yellow fever, have been found in the contents of the cranium or chest. In 
the abdomen the chief morbid changes are found in the liver, stomach, 
duodenum, and kidneys. The liver is not much enlarged, but is altered 
in color and texture. It presents a light yellow or fawn color, in some cases 
throughout the whole organ, and in others it is limited to particular parts. 

This change of color which differs much in degree in different cases, 
appears to depend on an infiltration of fatty matter and oil globules, with 
some degree of true fatty degeneration of the hepatic cells. This was first 
demonstrated by Dr. Alonzo Clark, of New York, in 1853, and has been 
confirmed by many other observers since. Dr. Schmidt, of New Orleans, 
from his numerous examinations during the epidemics of 1867 and 1878, 
not only recognized the marked accumulation of the fatty matter, but also 
pointed out the staining of the hepatic cells with haemoglobin from im- 
paired blood corpuscles. 

The spleen presents no marked alterations from the natural condition. 

The mucous membrane of the stomach is intensely congested, giving 
it a tumefied and reddened appearance, and in some places quite dark color. 

The accumulation of blood is chiefly in the small veins and capillaries. 
In some cases spots of blood extravasation or ecchymoses exist, and the 
stomach generally contains more or less of a dark brown or black liquid, 
which is identical with the black matter vomited before death. This dark 
liquid is made up of serum, altered blood corpuscles, epithelium, and the 
debris of ingesta. The duodenum and upper part of the small intestine 
present more or less of the same changes in the mucous membrane and its 
contents, as in the stomach. The glands of the ilium and mesentery 
show no marked morbid changes. 

The kidneys are found more or less congested in nearly all the cases ex- 
amined. The epithelium of the tubules has undergone some granular de- 
generation; the cortex is often swollen, yellowish-white, with congested 
and hemorrhagic spots; and small points of suppuration are sometimes, 
though rarely seen. The urine contains but little urea and uric acid, their 
places being supplied by leucin and tyrosin, and very generally a consid- 
erable amount of albumen. 

It also contains both blood and bile pigments, giving it a deep reddish 
yellow color. Dr. Schmidt has also called attention to some changes in 
the supra-renal capsules, and in the semilunar and other ganglia of the 
sympathetic nerves, none of which, however, appear to be peculiar to yel- 
low fever patients. 

*See Practice of Medicine by Roberts Bartholow, M. D., page 722. 



148 YELLOW FEVER. 

The blood in yellow fever undergoes no characteristic changes, unless 
it be a rapid crenation of the red corpuscles, with diffusion of the hae- 
moglobin in the serum and other parts of the body * Dr. J. G. Richard- 
son, of Philadelphia, claimed to have discovered a peculiar bacterium in the 
blood; but his observations have not been confirmed by other competent 
observers. 

Special Pathology. — Both the symptoms during life and the post mor- 
tem appearances, indicate that in yellow fever the general properties of 
the tissues, and consequently, the molecular changes concerned in nutri- 
tion, disintegration and secretion, are profoundly altered, in such direc- 
tions as to increase the susceptibility and diminish the vital affinity, in 
consequence of which the molecular changes are universally retarded or 
perverted from their natural direction. 

The direct action of the cause or causes in increasing the susceptibility 
is shown in the intensity of the febrile excitement, while the impairment 
of the vital affinity is shown by the impairment of the red blood corpus- 
cles, the molecular degenerations, the arrest of secretions, and especially 
by the general tendency to hemorrhages of a passive character. Besides 
these general morbid conditions, there is something in the nature of the 
efficient cause, that gives it a special tendency to establish a grade of in- 
flammatory, or at least, irritative action in the liver, kidneys and mucous 
membrane of the stomach and duodenum. This is shown as clearly by the 
almost uniform presence of epigastric tenderness, scanty and albuminous 
urine, and morbid bile during life, as by the changes seen in these organs 
after death. Yet the morbid actions set up in these several important or- 
gans, are not the cause of the general fever, but only an accompaniment, 
developing during its progress and often adding much to its fatality. 

I regard them as bearing the same relation to yellow fever as the mor- 
bid condition of the glands in the ilium and mesentery does to typhoid fever. 

Treatment. — The rational indications for treatment in this fever are: 
first, to suspend the further action of the exciting cause ; second, to lessen 
the intensity of the general excitability, and maintain the natural secretory 
actions; third, to counteract the development of local complications in the 
stomach, liver and kidneys; and fourth, to sustain the patient with proper 
nourishment, adjusted to the different stages of the disease. In fulfilling 
the first of these indications, the same attention to the supply of pure air, 
the rigid enforcement of cleanliness, and the prompt removal of all evacua- 
tions, is necessary, as I explained fully when speaking to you of the first 
indication in the treatment of typhoid fever. As high atmospheric tem- 
perature is, at least, one of the important elements in the causation of the 
disease, keeping the temperature of the sick-room reduced as near the 
standard of healthy comfort as possible, is very desirable, and the benefi- 
cial effects of this, may be increased by frequent sponge-baths, and cold 
applications to the head, and as complete rest as possible both for body 
and mind. If, in addition to high temperature, we have, as a specific 
cause, some modification of malarious infection pervading the atmosphere, 
whether it be in the form of germs or not, the proper use of disinfectants 
may be of some value. On the proper fulfillment of the several indications 
I have named, will depend, in a great degree, the success of the treatment. 

In proportion as the intensity of the morbid excitement can be 
moderated, and the natural molecular and secretory actions maintained 
during the first three days, in the same degree will the subsequent pro- 
gress of the disease, be rendered safe. 

*See paper in the New York Medical Journal for February, 1879, by H. D. Schmidt, M. D., of 
N.ew Orleans. 



TREATMENT. 149 

Concerning the best means for accomplishing this purpose, there is now 
and ever has" been, great diversity of opinion among those who have had 
the best opportunities for practical observation and experience. During 
the earlier epidemics in the days of Drs. Rush, Physic, Hosack and Bard, 
covering the half century preceding 1825, the purely antiphlogistic meth- 
ods of treating disease, were dominant, and the object now under consid- 
eration was sought to be accomplished by free venesection and evacuants. 
A large proportion of the more severe cases were bled freely, when seen 
during the first twenty-four hours from the commencement of the attack, 
and, as was claimed by Dr. Rush and many others, with decided benefit. 
It was applicable, however, to the first and second days only; if practised 
later, it onlv served to hasten the stage of dangerous prostration. It 
was claimed by the advocates of venesection, that free bleeding at the 
commencement of an attack, lessened the danger of copious hemorrhages 
from the stomach and other parts later in the progress of the case; and 
this was doubtless to some extent true. Yet Dr. Fenner tells us that he 
saw a man die with copious black-vomit after having lost near 4 litres or 
100 ounces of blood by venesection, and cups during the first stage. As 
the strictly antiphlogistic methods of treatment lost their popularity, the 
abstraction of blood in the treatment of yellow fever came to be limited 
to leeching and cupping, and the more active evacuants gave place to 
arterial sedatives, alteratives and Peruvian bark or quinine. So early as 
the year 1800, two eminent Spanish physicians gave large doses of Peru- 
vian bark, amounting in all to between 180 and 250 grams (|vi and Jvjii) 
during the first forty-eight hours after the initial chill, by which they 
claimed extraordinary success in arresting the progress, and curing severe 
cas2s of this fever. They gave from 8 to 12 grams (3ii to 3iii) of the 
bark every two hours, commencing immediately after the initial chill.* 

During the prevalence of the fever in New Orleans in 1847, and from 
that time to 1853, Dr. E. D. Fenner and others gave from 0.66 to 2.00 
grams (gr. x. to gr. xxx.) of quinine at once, and repeated the dose from 
one to three times in the twentv-four hours, during the first two or three 
days of the fever, with the effect of rapidly reducing the temperature and 
general excitement, causing free perspiration, and arresting the further 
progress of the disease. The epidemic of 1847, however, was mild in its 
character, and so were all the seasons of the recurrence of the fever from 
that date until the very severe prevalence of the disease in 1853. During 
the epidemic of the last named year, Dr. Fenner himself tells us that he 
could not obtain the same beneficial effects from the large doses of qui- 
nine, and was obliged to substitute other and milder means in the man- 
agement of the disease. f I should remark that Dr. Fenner and others, in 
giving the full doses of quinine, generally gave some calomel with them. 
Since the promulgation of the more recent doctrines concerning the treat- 
ment of fevers, mainly by antipyretics, we have had the severe epidemics 
of yellow fever of 1867 and 1878-79. In the latter, more especially in 
New Orleans, the antipyretic treatment by cold baths, packs, the wet sheet, 
and cold water spray, was tried in all forms and with all degrees of per- 
sistence, but with no specific results other than the temporary reduction of 
the temperature. And one physician who had invented a most ingenious 
bed and apparatus for carrying out antipyretic treatment, heroically died 
from the disease while endeavoring to demonstrate the value of his appa- 
ratus, and the particular treatment for which it was designed. As the 

*See Philadelphia Medical and Physical Journal for 1808. Also Transactions of the Amer. Med. 
Association. Vol. vii. p. 546. 

t^ee Report on the epidemics of Louisiana, etc., by E. D. Fenner, M. D., in Trans. Amer. Med. 
Association, Vol. vii. p. 421. 



0.5 grams 


gr. 


15.0 c. c. 


3iv 


15.0 " " 


3iv 


6.0 " " 


3iss 


60.0 " " 


!« 


60.0 " " 


!" 



150 YELLOW FEVER. 

the tendency to develop local hyperseinia and irritation in the stomach, 
liver and kidneys, causes in many cases a persistent tendency to reject all 
remedies and nourishment by Vomiting, we must practically unite the meas- 
ures calculated to repress or lessen these important local complications, 
which I have designated as the third object to be accomplished, with those 
for fulfilling the second. In doing this, if called to a patient with severe 
yellow fever soon after the initial chill, we find the epigastric distress, 
tenderness, and tendency to vomit, prominent symptoms; from six to 
twelve leeches may be applied to the epigastrium, or in their absence, 
free cupping over the dorsal and lumbar portions of the spine, with mus- 
tard sinapisms to the epigastric region; hot mustard bath for the feet, 
with cold cloths to the head; and if the skin be very hot and dry, cold 
sponging over the face, neck, and trunk of the body, while internally may 
be administered, for the triple purpose of helping to allay gastric irrita- 
tion, lessening general febrile excitement, and promoting the more im- 
portant secretory actions, the two following formulae: 

IjL Acidi Carbolici 0.5 grams gr. viii 

Grlycerinae 
Tincturse Gelsemii 
Tincturae Veratri Viridis 
Tincturae Opii Camphoratae 
Aquae 

Mix, and give four cubic centimetres (fl 3i)» or a teaspoonful every two, 
three or four hours, according to the urgency of the symptoms. Also, 

Jy, Hydrargyri Chloridi Mitis 0.8 grams gr. xii 

Sodii Bicarbonatis 2.0 " " xxx 

Mix, divide into six powders; one of which may be given, mixed with 
a very little moistened sugar, half way between the doses of the liqud 
formula just given. If the case is located in an actively malarious dis- 
trict, as shown by the coincident prevalence of cases of ordinary inter- 
mittent and remittent fevers, I would give as early as possible in addi- 
tion to the foregoing, one or two full sedative or antipyretic doses of qui- 
nine, administering it either hypodermically, or by rectal enema. 

If the bowels do not move until two hours after the last of the six pow- 
ders are taken, a laxative should be given sufficient to procure one or two 
free evacuations. As soon as this has been accomplished, the action of 
the skin and kidneys may be further promoted by giving an equal mixture 
of liquor ammonii acetatis and nitrous ether, in doses of four cubic centi- 
metres, or one teaspoonful, between the doses of the carbolic acid formula. 
The efficient carrying out of the measures I have detailed, will necessarily 
occupy the first two days, at the end of which time, if any beneficial re- 
sults are being produced, all the more important symptoms will have been 
mitigated. The temperature will have been lowered, the restlessness and 
pains abated, the urine more free with little or no albumen, the skin 
moist, and the patient more restful. 

If such has been the result, the veratrum viride should be excluded 
from the carbolic acid formula, lest its further use should increase the 
sedative action so far as to renew the gastric irritability and vomiting. 
In other respects the treatment may be continued until either conva- 
lescence is established, or the yellow color and other symptoms of the 
stage of apyrexia begin to appear. If this period of calm and rapid sub- 
sidence of the febrile symptoms commences, the leading object is to pre- 



TREATMENT. 151 

vent the congested gastric veins as well as the smaller blood-vessels 
generally, from yielding so far as to allow the escape of blood in the form 
of black vomit or other hemorrhagic appearances. The patient must be 
kept entirely at rest, and only the most bland and unirritating materials 
allowed to enter the stomach for nourishment. The medicines adminis- 
tered should be such as are calculated to sustain the tone and integrity 
of the vascular system, and lessen the tendency to further deteriora- 
tion of the blood itself. Moderate but frequently repeated doses of 
the tincture of chloride of iron given well diluted; the oil of turpentine 
emulsion carefully prepared as 1 directed when speaking of the treatment 
of typhoid fever; and small doses of quinine or strychnine with a mineral 
acid, would appear to constitute the best means for accomplishing the 
object just stated. But whichever of these or other remedies are chosen, 
the mode of administration must be such as is least likely to provoke 
vomiting, or any degree of irritation in the stomach. The required 
amount of either quinine or strychnine could be readily given by hypo- 
dermic injection, and much of the nourishment needed might be given in 
the form of enemas. 

If this critical period is passed without being followed by copious hem- 
orrhages, as indicated by vomiting of dark "coffee ground" material and 
rapid prostration, the subsequent management may be similar to that of 
a moderate grade of typhoid fever, only being more careful to insist on the 
most bland and simple nourishment, with as perfect rest of body and 
mind as possib'e, until convalescence is fully established. Throughout 
all the active stage of the disease, the patient's thirst should be alleviated 
chiefly by frequent bits of ice, with here and there a spoonful of cold water, 
or of orange-leaf tea ; and the nourishment should be chiefly milk and lime- 
water, given in doses of only one or two tablespoonfuls, but frequently re- 
peated. If any meat broths are allowed, they should be properly seasoned 
with salt, and given in the same limited doses as the milk and lime-water. 

In the more advanced stages, if a gentle stimulant is required, small 
doses of well prepared tea or coffee will supply the want better than any 
other articles. Solid food of any kind appears to be unsafe, until after full 
convalescence, and even then must be given with caution. During the 
active stage of some cases, excited delirium and persistent wakefulness 
exist, and may be relieved by using judiciously morphine, combined with 
atropia hypodermically. But morphine and other preparations of opium 
must be used with great caution, lest they help to check the action of the 
kidneys. The recovery after full convalescence is generally rapid, and 
not attended by any troublesome sequelae. 

Prophylaxis. — In relation to the best means for preventing the develop- 
ment and spread of yellow fever, I would state that the most important of 
all the measures devised for these purposes, are such as have for their object, 
the removal of one or more of the conditions known to be necessary for 
the production and spread of the disease. 

Of these conditions, the one most readily under human control is the 
contamination of the atmosphere from local sources of vegetable and ani- 
mal decomposition. It is well known that the chief sources of such de- 
composition are imperfect and uncleanly sewers or cess-pools, foul and 
stagnant water, and low, moist ground, rich in vegetable matter. 

To remove these sources of atmospheric impurity early in each year, and 
keep them thoroughly removed until the close of the warm season, and 
thereby prevent the supply of local material on which the essential cause 
of yellow fever depends for its propagation, is the only reliable safeguard 
against the development of this disease in any place within the geograph- 



152 YELLOW FEVER. 

ical range of its prevalence. If this is neglected until the atmosphere of 
a»y locality becomes filled with miasms as a pabulum for the fever poi- 
son, and the summer temperature prove continuously high, the disease 
will prevail and spread in defiance of all the inland quarantines that can 
be devised. But if a sufficient degree of cleanliness in regard to streets, 
alleys, gutters, sewers and stagnant waters, to prevent the atmosphere 
from becoming filled with the products of decomposition and impurities, 
is secured early in the season, and faithfully maintained until the 
frosts of autumn, there will be no danger of the prevalence of yellow 
fever, either by importation or otherwise. The point of vital importance 
is to prevent the development of the noxious material that constitutes the 
pabulum on which the essential cause of the disease feeds or out of 
which it originates. 

In addition to this, the municipal and health authorities of every impor- 
tant city or town on the coast of the Gulf from the Mexican boundary to 
Charleston on the Atlantic; on the Mississippi from New Orleans to St. 
Louis; on the Red River below Shreveport; on the Ohio below Pittsburgh, 
and on the principal lines of railroad in immediate connection with such 
cities and towns, should deliberately select the nearest unoccupied, dry, 
elevated place; containing pure air and good water, and as readily accessi- 
ble as possible, to which all families willing to go could be speedily re- 
moved from an infected street or section of a town or city, and accomo- 
dated in tents or other temporary structures until they could safely return 
to their homes. 

Wherever this principle of speedy removal was acted upon by our 
army, it proved entirely successful in stopping the spread of the disease 
among the soldiers, and its imperfect and limited adoption at Memphis in 
1879, was of great value. 

If the proper places were carefully selected beforehand, and a supply 
of tents or other material kept under the control of the proper authori- 
ties, so that on a first appearance of the disease in a neighborhood those 
exposed could be removed without delay, and ordinary supplies of pro- 
visions for the poor dealt out only at the camp or camps, there would be 
but little difficuly in limiting the local spread and fatality of any epidemic. 
While such camps would chiefly operate for the benefit of the poorer 
classes (and wherever it should be possible to find the proper grounds on 
railroad lines within a radius of from ten to twenty miles of the city, many 
of the workingmen could go in every morning and continue many kinds 
of work), all who were able to provide for themselves and their families 
away from home and were not thoroughly acclimated, should be encour- 
aged to go early and freely, the only condition imposed being that they 
should not stop until they had passed entirely north of the climatic zone 
of the yellow fever. The only internal or inland quarantine regulations 
required are the selection of suitable and well prepared healthy stations 
a few miles from each of the more important cities on the great lines of 
travel, whether by river or railroad, where boats and trains shall halt long 
enough for inspection, and if any are found sick of the fever they shall be 
transferred directly to the station and cared for, the boat or car being 
thoroughly ventilated, and allowed to proceed with all the well persons, to 
any proper northern destination. The great northwestern region bounded 
on the east by Waukesha, Mackinac and Marquette, extending indefinitely 
westward over the northern peninsula of Michigan, northern Wisconsin 
and Minnesota; and the whole Alleghany range in the northeast, from 
Virginia to the Adirondacks, are sufficient to accommodate every unac- 
climated person in the lower Mississipi Valley and in our southern sea- 



PROPHYLAXIS. 153 

port cities; and they could no more spread the yellow fever in those re- 
gions than intermittent fever could be spread on Mount Washington. 

The same principles apply to commerce and business. There is no pos- 
itive evidence whatever, that the disease is ever transmitted by simple 
contact with the sick, nor by either articles of clothing or merchandise 
that have been freely exposed to the air outside of an infected locality. 
It is only when the infected air of the locality where the disease is pre- 
vailing, is shut up in the hold or apartments of a ship, boat or car, or 
boxed up with goods in boxes or trunks, that it can be carried to distant 
places and retain its active properties. And even when so carried, it 
must be let out in an atmosphere in the new locality at the proper high 
temperature and containing the necessary local miasms or impurities, or it 
becomes utterly harmless. All that is necessary, therefore, is to have all 
ships, boats, and cars, carrying freight, stopped at suitable places outside 
of populous towns, inspected, all parts thoroughly ventilated and cleansed; 
and where goods had been packed in bales, boxes, or trunks, the same 
opened and aired before they are received by the parties to whom they 
are consigned. 

The proposition that, on the appearance of an epidemic in any given 
place, all persons not being fully acclimated or protected by previous at- 
tacks of the disease, should be encouraged to immediately remove to 
healthy districts; such as were pecuniarily able, to go beyond the yellow- 
fever zone; and those who were not able, to go into well-selected camps in 
the vicinity, was subjected to a pretty fair test in Memphis, in the summer 
of 1879. 

On the outbreak of the epidemic the utmost facilities were afforded for 
all who wished to go to the North, and three camps were established in 
judiciously selected localities, within twenty or thirty miles of the city, 
in which many hundreds of the poorer classes took refuge. The result 
was most gratifying. Those in the camps remained perfectly free from 
the disease; only a very few of those who fled to the North were taken 
sick after their departure, and yet the population left in the city was re- 
duced to ten or twelve thousand, and the aggregate number of deaths 
from the fever during the whole season was only about 550, instead of 
2,500, as during the epidemic of 1878. 

The suggestion to carefully select stations in proper places along the 
lines of travel and commerce, both by rivers and railroads, at which boats 
or cars from infected places, should be stopped for inspection, and, when 
necessary, thoroughly ventilated and cleansed, with the removal of any 
found sick to a hospital for proper care, while the well were allowed to 
proceed on their way, thereby substituting systematic inspection, with en- 
forcement of ventilation, cleanliness, and care of the sick, in the place of 
quarantines, has been tested only to a limited extent. A station of this 
kind was established during the summer of 1879, at Island No. 1, 
below Cairo, and in a less perfect manner on the Ohio, below Louisville 
and Cincinnati. The quarantine station, fourteen miles below St. Louis, 
was also managed partly on the same plan. The results at each of these 
places were most beneficial, and fully demonstrated that if the plan of es- 
tablishing inspection stations, with temporary hospital accommodations at- 
tached, should be carried out in the systematic manner I have suggested, 
it would afford a far better protection against the spread of the disease, from 
one place to another, than the ordinary methods of quarantine. 



154 ERYSIPELAS. 



LECTUEE XV-III. 

Erysipelas— Its History, Causes. Symptoms, Diagnosis, Prognosis, Pathological Anatomy, Special 
Pathology, Treatment and Prophylaxis. 

GENTLEMEN : — Erysipelas presents itself to us in two aspects. In 
one, it has the characteristics of a general acute disease, accompanied 
during its progress by a peculiar local inflammation. In the other, it is 
chiefly characterized by the local inflammation occurring in connection 
with wounds, injuries, etc., not necessarily preceded or accompanied by 
general fever. The first is called idiopathic erysipelas, and the second, 
traumatic. The French designate the one as medical and the other as 
surgical erysipelas. It is the first only that will occupy our attention at 
this time, as the second is always fully considered in the department of 
surgery. Sporadic cases of idiopathic e^sipelas are met with in general 
practice every year, and at times it assumes an epidemic form and extends 
its prevalence over large districts of country. One of the most noted of 
these epidemics prevailed in our country from 1841 to 1846. During those 
years it extended over large portions of Vermont, Massachusetts, New 
York, some parts of Pennsylvania, Ohio, Michigan, Illinois, and Indiana. 
It commenced in the Eas ern states in 1841, extended westward through 
New York with great severity during 1843, '44, and invaded many places 
in the states intervening between New York and the Mississippi, between 
1844-46. 

Hirsch alludes to this epidemic as extending over a great part of North 
America, and both he and Zuelzer, in his chapter on erysipelas in Ztemssen's 
Cyclopaedia, intimate that it was not true erysipelas, but "an acute infect- 
ious disease closely related to diphtheria."* 

As it was my fortune to see some part of that epidemic, in the years 
1843-44, as it prevailed in Binghamton, New York, where I was then 
practicing, I must differ from this opinion of these learned writers. The 
cases that came under my observation presented all the symptoms charac- 
teristic of erysipelas in a strongly marked degree, while nothing peculiar 
to diphtheria was observed at any stage of their progress, neither did I see 
a single sequel usually seen after diphtheritic attacks. 

The disease as it prevailed in Vermont, New Hampshire, and other parts 
of the New England States, was fully and accurately described by Drs. J. 
A. Allen, Charles Hall, and George J. Dexter ; in the Western part of 
New York by Dr. Sanford B. Hunt ; in Indiana by Dr. George Sutton, 
and in Illinois by Dr. D. Meeker, and I have failed to find a single allusion 
by any of these writers to a diphtheritic exudation, either upon the fauces 
or elsewhere, or to any symptoms specially analagous to those of diphtheria. f 

Epidemics of erysipelas have prevailed and been accurately described 
under various names ever since the days of Hippocrates. 

Epidemics of the disease occupying limited districts have occurred in 
almost all parts of this country, at different periods from the first settle- 
ments to the present time. 

An epidemic of considerable severity prevailed in this city in the sum- 

* See Ziemssen's Cyclopaedia, Vol. II. p. 424. 

fFor a more full account of this epicLmic, see Copeland's Dictionary of Medicine, edited by 
Charles A. Lee, M. D., Vol. I, pp. 954-5-6-7. 



CAUSES. 155 

mer and autumn of 18G3, and also in many other places in this and the 
adjoining- States during the years 1863-64.* 

During- the time the disease was prevailing in this city, in the latter part 
of the summer and autumn of 18G3, the water in the Chicago River had 
become so impregnated with the blood and offal from slaughtering-houses 
on its banks, that the fish all died, and the stench from it rendered the air 
offensive to the nostrils over large portions of the city. Many of the phy- 
sicians attributed the erysipelas, as well as a coincident unusual prevalence 
of typhoid fever, to this impregnation of the a:r with putrid animal matter. f 
As it was prevailing at the same time, however, in remote interior districts, 
it is probable that other causes at least contributed to its production here. 
A fact of great practical importance is, that in nearly all the epidemics of 
erysipelas, women undergoing confinement in child-bed are extremely 
liable to be attacked with puerperal fever or, in other words, erysipelatous 
inflammation of the peritonaeum. This was notably true in the great 
epidemic from 1842-46. According to Drs. Hall and Dexter, in the 
county of Caledonia, Vermont, thirty cases of puerperal peritonitis occurred 
within a few weeks, of whom only one recovered. In the town of Bath, 
N. H., with not more than fifteen hundred inhabitants, twenty mothers 
died with the puerperal disease. \ The same connection between the 
prevalence of erysipelas and puerperal fever was n vticed in all parts of the 
country; and in all places the puerperal disease was exceedingly fatal. It 
is well for each of you to remember this connection between erysipelas 
and puerperal fever, and be exceedingly careful about attending cases of 
obstetrics while at the same time attending cases of erysipelas, as there is 
much evidence going to show that a physician, under such circumstances, 
may convey the specific infection to the lying-in woman. 

Causes. — In a general sense, I may say that all the circumstances 
which have been mentioned as favoring the development and spread of 
typhoid and typhus fevers, also act as predisposing influences in favoring 
the occurrence of erysipelas; yet it is highly probable that the immediate 
or specific cause of the latter is a subtle organic poison or idio-miasm, 
derived from the retrograde metamorphoses of animal matter, which may 
take place either within or without the living body. In many of the 
sporadic cases the specific cause is evolved in the system by derangement 
of the processes of disintegration and elimination. Whatever interferes 
with the natural tissue changes, by preventing the proper oxidation of the 
tissue materials and their conversion into the forms capable of ready excre- 
tion or elimination, will favor this result. Consequently, you will find 
those who habitually use alcoholic drinks; those living in small, damp, and 
poorly- ventilated apartments; and those confined to over-crowded rooms, 
with inadequate supply of air, to be more liable to erysipelatous attacks. 
Cases arising from the absorption of poison generated on the surface of ill- 
conditioned wounds, ulcers, etc., are numerous among the traumatic forms 
of the disease. Very strong proof has been given that sewer-gas is capa- 
ble of sometimes causing attacks of the disease. For instance, beds 
standing over or alongside of sewer-pipes from which gases escaped, have 
been found to impart erysipelas to their occupants, but Avhich was imme- 
diately changed by simply repairing the pipes.] 

Dr. Orth claims to have induced erysipelas in rabbits by inoculating 

* See Report on Practical Medicine and Epidemic Diseases, by N. S. Davis, M. D., Vol. Trans. 111. 
State Medical Society, 1861, p. 14. 

t See a short but interesting article on this subject, by Dr. E. Andrews, in the Chicago Medical Ex- 
aminer, Vol. V, p. 17. 1864. 

t >iee Account of the Erysipelatous Fever, as it appeared in the northern part of Vermont and 
New Hampshire in 1812-43, in Amer. Jour. Med. Sciences, Jan., 1814. 

|| See Ziemssen's Cyclopaedia of Practical Medicine, Vol. II, p. 440. ' 



156 ERYSIPELAS. 

them with the serum from the vesicles on an erysipelatous surface, ami 
also by using the blood of patients affected with the disease. While it is 
not difficult to account for cases of sporadic and traumatic erysipelas, by 
supposing the ex stence of a local animal poison, it is not so easy to see 
how such a poison could be generated and diffused so widely as to cause 
the prevalence of epidemics over extensive districts of country. It is a 
well-known fact, however, that a variable quantity of organic albuminoid 
matter generally exists in the atmosphere; and I see no reason why, under 
some combination of atmospheric conditions, this might not be so changed 
as to constitute the special infection for producing an epidemic of 
erysipelas. 

Neither age, sex, nor season of the } T ear appear to exert much influence 
over the susceptibility to this disease. The greater number of cases have 
occurred during the active period of adult life — that is, between 20 and 
45 years of age. But cases are liable to occur at any period of life, 
between the first few days after birth and old age. 

Some have claimed that a larger number of females suffer from attacks 
of the disease than of males. There is, however, no uniformity in this 
respect; for close examinations of the results of several epidemics show 
that in some seasons the majority of those attacked were males, and in 
others females. While the prevalence of the disease is not limited to any 
particular part of the year, it has occurred most frequently in the spring 
and autumn. One attack of erysipelas does not in any degree lessen the 
susceptibility of the individual to subsequent attacks. There is no proof 
that the disease is communicable from one individual to another by per- 
sonal contagion through the atmosphere; but it is readily communicated 
by actual contact or inoculation. 

Symptoms. — Idiopathic erysipelas, whether occurring sporadically or in 
the midst of an epidemic, usually begins with a feeling of indisposition 
similar to that which precedes the active stage of most febrile affections. 
This is seldom noticeable more than from one to three days, when a cold 
stage, varying from slight chilliness to a decided chill of lrom fifteen to 
forty-five minutes' duration, marks the commencement of the active phe- 
nomena of the disease. The brief, and generally slight chill, is immediately 
followed by more or less pains in the head, back, and limbs; some flushing of 
the face; dryness and heat of the skin; increased frequency and fullness of 
the pulse; some thirst; a white fur on the tongue; scantiness of urine; and 
quiet or inactive state of the bowels, with loss of appetite and some thirst. 

In the more severe cases the headache is severe and not unfrequently 
accompanied by vomiting of matters mixed with bile. In cases of average 
severity the febrile symptoms develop with such rapidity that at the end 
of the first twenty-four hours the temperature ranges between 39° and 4<''~ 
C. (10'2 ° and 104° F.), and the pulse from 90 to 110 per minute. A mod- 
erate increase usually continues until the end of the third day, when the 
general febrile symptoms reach the climax of their intensity, the temper- 
ature being in many cases 40.5° or 41 C C. (105° or 106° F.), the pulse 120, 
and the urine containing more or less albumen. During the fourth, fifth, 
and sixth days the aggregate of general symptoms remains nearly the 
same, although the temperature may fluctuate to the extent of two or three 
degrees every day, the maximum being in the morning quite as often as 
in the evening. Decided defervescence usually commences between the 
fifth and seventh days, and progresses to the full establishment of conva- 
lescence, between the ninth and eleventh days. 

In some instances, coincident with the initial chill, or immediately after 
it — but more generally in the latter part of the first day of fever — the 



SYMPTOMS. 157 

patient complains of some soreness in the fauces, which on inspection pre- 
S( nt a deep red appearance, with slight tumefaction of the mucous mem- 
brane. Sometimes a sense of soreness, stiffness, or tension is felt in some 
part of the cutaneous surface, but at first no redness. In most cases, on 
the morning of the second or third day, a deep red spot has made its 
appearance on the face near the wing of the nose, or at the lobe of the ear, 
the nates, the vulva, or some part of the extremities, usually at the place 
that had been previously feeling tense and sore. The red spot is at first 
small, but accompanied by tumefaction, heat, and soreness, and is bounded 
by an abrupt, well-defined margin. It commences far more frequently on 
the face than on any part of the body or extremities. With the appear- 
ance of the inflammation on the surface the soreness and redness of the 
fauces disappear; but the general febrile symptoms continue unabated, or 
increase in intensity. The local inflammation extends rapidly in all direc- 
tions, and usually covers the whole face, ears, and mastoid spaces in from 
two to three days; and in severe cases it continues its spread over the 
whole head and neck, to the shoulders and back. In extending over the 
face, the tumefaction from infiltration into the subcutaneous areolar tissue 
is sufficient to close the eyelids and make the whole surface, appear 
intensely red and much swollen, while vesications or blisters, varying in 
size from the circumference of a pea to that of a hickory nut, make their 
appearance, mostly upon the cheeks, forehead, and ears. If the inflamma- 
tion extends over the broader surfaces on the trunk of the body, or on the 
lower extremities, the blisters are sometimes much larger; and though 
generally filled with a transparent serous fluid, yet in unusually severe cases 
the fluid is more turbid and dark purple, from intermixture of blood. The 
external erysipelatous- inflammation generally ceases its further extension 
in from five to seven days, and from that time declines, pari passu, with 
the decline of the general fever. As soon as the inflammation begins to 
abate, the redness changes to a darker hue, the swelling diminishes, the 
vesicles shrivel and soon become dry and covered with a thin scab or crust, 
composed of the dried serum and shriveled cuticle, and of a dark brown 
color. The tumefaction also diminishes rapidly, allowing the eyelids again 
to open; and by the time defervescence is complete, the whole recently 
red, burning, and swollen surface presents a shrunken, dingy, or brownish 
aspect, rough from exfoliating cuticle, but free from heat and pain. 

While the description I have now given you applies with sufficient accu- 
racy to the great majority of cases of erysipelas, as they are met with by 
the general practitioner, there are many and important deviations from it 
in individual cases. One of these deviations consists in the presentation 
of a milder grade of general fever, a slower spread of the local inflamma- 
tion, less tumefaction, little or no vesication, but persistent in duration 
until large surfaces had been occupied or passed over, the redness and heat 
disappearing from the parts first attacked, whiie it is still extending to new 
parts on its margins. I recollect one nursing infant on whom the inflam- 
mation spread thus superficially, but persistently, until it had extended 
over every square inch of its cutaneous surface, and occupied nearly two 
weeks of time; ending finally in diarrhoea and fatal exhaustion. In a very 
few instances of this superficial variety I have seen the inflammation, after 
having passed successively over the face and scalp, return to the part first 
attacked and go over the same surfaces a second time; but all of this 
variety of cases coming under my care have recovered, except the infant I 
have just mentioned. During the prevalence of erysipelas in this city in 
1863, a case occurred in the practice of Dr. W. H. Byford, in which an 
adult male, aged 45 years, had a regular attack of fever, followed by 



158 ERYSIPELAS. 

erysipelatous inflammation, commencing on the nose and spreading rapidly 
until it had occupied the whole face and scalp, and seven days of time. 
Defervescence then commenced, and by the thirteenth day convalescence 
appeared to be fully established. In less than forty-eight hours he was 
again attacked by a chill, followed by fever and a reappearance of the 
erysipelatous inflammation on the nose, just as at first. The febrile symp- 
toms continued, and the external inflammation spread over precisely the 
same surface as in the first attack, and completing its course in five days, 
declined so rapidly that on the seventh day he was again fully conva- 
lescent. But on the very next day he was again attacked in the same 
manner, by a chill followed by fever, and a fresh eruption of the erysip- 
elatous inflammation on the nose, which again, for the third time, regularly 
extended over the whole face and head, presenting every characteristic of 
the disease, and again completing its course in seven days. The first 
attack commenced on the 5th of June, and the third ended on the 3d of 
July, soon after which the patient was sent out of the city for a change of 
air, and he remained free from the disease. He was treated from the 
beginning to the end with efficient doses of the tincture of chloride of iron. 
Dr. By ford, in recording the case, remarked that in a practice of twenty- 
five years he had seen no parallel case of relapsing erysipelas.* 

Another deviation from the ordinary typical course of" the disease con- 
sists in a greater amount of subcutaneous infiltration and consequent 
swelling, making the skin very tense, dark purplish color, the vesicles filled 
with dark bloody serum, and the accompanying fever more of a typhoid 
character, with more or less delirium, subsuitus, and cold extremities. In 
these cases there is apt to be suppuration in those parts of the areolar 
tissue most tensely engorged, such as the loose tissue under the eyelids, 
behind the angle of the jaw, and in the scalp. 

Three such cases came under my care in the Mercy Hospital during the 
epidemic of 1863. In two of them the destruction of the tissue under the 
eyelids by suppuration was so extensive that when recovery had taken 
place, the contraction of the cicatrices caused a moderate eversion of the 
tarsus of the lids, with inability to completely close them. 

A still more important deviation from the ordinary course of the disease 
is presented by those cases in which the erysipelatous inflammation, instead 
of appearing on any part of the cutaneous surface, attacks the fauces, 
tongue, pharynx, and sometimes the bronchial tubes and membranes of the 
brain. During the severe epidemic of 1843-44 there were many cases in 
which the whole force of the inflammation fell upon the fauces, tongue, 
and pharynx, causing those parts to become dark red, and so much swollen 
as to render breathing and deglutition extremely difficult. The lips and 
swollen tongue became early covered with a thick, dry, and black coating, 
so prominent that in many places the disease was popularly styled "the 
black tongue." When the inflammation attacked the bronchial tubes there 
was severe burning pain in the chest, very distressing cough, with great 
difficulty of breathing, and rapid exhaustion. If the membranes of the 
brain became involved, it gave rise to severe pain in the head, early and 
excited delirium, very frequent pulse, followed in two or three days by 
coma, dilated pupils, and death. A very large proportion of all those in 
which the local inflammation failed to develop on some part of the cutane- 
ous surface, but attacked more internal structures, terminated speedily in 
death. A much smaller proportion of this class of cases was noticed during 
the epidemic of 1863-64 than in that of 1843-44. Most writers state that 

* See Chicago Medical Examiner, Vol. IV, pp. 495-6-7, 1863. 



DIAGNOSIS. 159 

the erysipelatous inflammation, after having been established in some part 
of the cutaneous surface, is liable to suddenly recede and attack the 
stomach, meninges of the brain, or other internal structures; and it is 
probable that such cases have been occasionally observed, though none 
have ever come under my own observation. 

Diagnosis. — In most cases erysipelas is easily distinguished from all 
other acute febrile affections. The appearance of an inflammation on 
some portion of the surface soon after the development of general fever, 
presenting a deep red color and abrupt margins, with burning pain, and a 
disposition to spread by continuity, is so characteristic or unique, that the 
most inexperienced observer can hardly err in his diagnosis. And yet I 
have met with several cases of acute eczema rubrum, especially on the 
face, that had been mistaken for erysipelas and treated accordingly. But 
if you remember that acute eczema simply presents a red surface closely 
studded with minute pointed vesicles, accompanied by fiery heat and itch- 
ing, the red surface having no abrupt margin in any part of its circum- 
ference, and the minute vesicles weeping a serous fluid whenever they are 
broken by friction or scratching, and accompanied by very little, if any, 
gen'-ral febrile symptoms, you will exhibit extraordinary skill in blunder- 
ing if you confound it with erysipelatous inflammation. 

Erythema is distinguished from erysipelas by its presenting a simple 
red surface, with little or no tumefaction, accompanied by no general fever, 
and without an abrupt margin. When the inflammation accompanying 
erysipelatous fever is restricted to the fauces, tongue, and pharynx, there 
may be some danger of confounding it with either catarrhal or diphtheritic 
inflammation of those parts. From the first, however, it is distinguished 
by the deeper, darker redness of the inflamed surface; its more rapid 
spread and the greater temperature of the parts, and the far more violent 
and dangerous general febrile symptoms accompanying it. From the sec- 
ond it is distinguished by the absence of any diphtheritic membranous 
exudation; by the greater dryness and heat of the surfaces involved; and 
the more speedy formation of a dark brown or black coating over the 
swollen tongue and fauces. 

Prognosis. — Idiopathic erysipelas, as it occurs sporadically or in mild 
epidemic form, is a self-limited general febrile affection, almost always 
tending to recovery, and consequently productive of a very low ratio of 
mortality. But in its more severe epidemic forms the mortality occasioned 
by it has been very great. Striking examples of the latter were presented 
in many of the places visited by the disease during the wide spread epi- 
demic that prevailed from 1841 to 1846. The epidemic of 1863-64 was of 
milder character. During the six months ending March 1st, 1864, there 
came under my care in the wards of the Mercy Hospital in this city, 
twenty-one cases, and forty-five more in private practice. Of these sixty- 
six cases only one died. The one fatal case was a female child only four 
weeks old, the symptoms accompanying which I have already alluded to.* 
It may be stated as a general rule that erysipelatous fever, accompanied 
by inflammation on any part of the cutaneous surface, tends strongly to 
recovery, the convalescence being established between the seventh and 
fourteenth days. But when this variety of fever is attended by the de- 
velopment of inflammation in any of the internal membranes, whether 
mucous or serous, its progress involves great danger to the life of the 
patient. 

Pathological Anatomy. — Fatal cases of erysipelas leave no internal 

♦See report on Practical Medicine and Epidem'cs, in the Transactions of the Illinois State Med- 
ical Society for 1864 p. iG. 



100 ERYSIPELAS. 

changes of structure which are in any degree characteristic of this variety 
of fever. In different cases have been found all the usual appearances of 
inflammation of the meninges of the brain, pleura, peritoneum and other 
serous membranes ; also of the mucous membranes in the throat, nasal 
passages, stomach and upper part of the intestines, as well as in the bron- 
chial membranes and parenchyma of the lungs. But all these appearances 
resulted from internal complicating inflammations, and not from changes 
necessarily belonging to the erysipelatous affection. The blood has been 
described as thinner and darker color than natural, and sometimes con- 
taining a few motionless bacteria. The latter are found much more abun- 
dantly in the serum of the vesicles and that infiltrating the sub-cutaneous 
arealor tissue of those parts of the surface involved in the erysipelatous 
inflammation. They appear to be indentical, however, with the bacteria 
found in serous and other organic liquids undergoing deteriorative changes, 
having no connection with erysipelas or any other kindred disease. In a 
large proportion of the fatal cases, the spleen has been found engorged 
with dark blood and enlarged, and the cortical substance of the kidneys 
in a state of active hyperasmia. 

Special Pathology. — The general character of the erysipelatous fever, 
together with the peculiar mode of development, spread, and disappear- 
ance of the accompanying cutaneous inflammation, furnish strong evidence 
that the disease arises from the presence in the blood of a specific 
materies morbi, which so acts upon the properties of the living tissues as 
to increase their elementary susceptibility and pervert in a peculiar man- 
ner the vital affinity, inducing thereby those singular molecular changes 
which so clearly distinguish the erysipelatous from all other grades of in- 
flammation. The very general tendency of the disease to disappear 
spontaneously after from one to two weeks' duration, shows that the 
specific causative material is either incapable of continued propagation, 
or is rapidly destroyed and eliminated from the living system during the 
progress of the morbid processes which its presence has induced. But of 
the identity and nature of the specific poison, and of the exact mode of 
its elimination, no satisfactory knowledge has yet been obtained. 

Treatment. — If the opinion I have just expressed concerning the de- 
pendence of idiopathic erysipelas upon a specific poison which has in some 
way gained access to the living tissues through the blood, is true, the 
leading indications for treatment are, to prevent the further introduction 
of the poison ; and to aid in either neutralizing or expelling that which is 
already pervading the fluids and solids of the body. The first is to be ac- 
complished by placing the patient and his immediate surroundings in as 
good sanitary condition as possible. The second, by keeping the secretory 
and eliminating functions as near naturally active as possible, and giving 
internally such specific or antiseptic medicines as experience has shown 
to be capable of exerting some influence over the progress of the disease. 
If called early, and the lever is active, with coated tongue, dry skin, scanty 
and high colored urine, and quiet bowels, I endeavor to promote the ex- 
cretory functions by giving every three or four hours a powder containing 
the compound opium and ipecac powder and nitrate of potassium, each 
three decigrams (gr. v.) and calomel thirteen centigrams (gr. ii), until 
four doses have been taken, and follow them by a saline laxative sufficient 
to cause one or two intestinal evacuations. After this the bowels seldom 
need further prompting, and the action of the skin and kidneys may be 
sufficiently sustained by suitable doses of the spirits of nitrous ether. To 
exert a specific action upon the exciting cause in such a way as to lessen 
the severity and duration of the disease, we may give the tincture of the 



TREATMENT. 161 

chloride of iron, the sulphites of sodium and calcium, or the dilute sulph- 
urous acid, in suitable doses and sufficiently frequent to freely impregnate 
the blood. In far the larger number of cases I prefer the tincture of 
chloride of iron, and commence giving it from the beginning of the treat- 
ment in doses of from 1.5 to 2.0 cubic centimetres (m. xxv to xxx) 
well diluted with sweetened water, and repeated every three or four 
hours, until the fever begins to decline, and the inflammation ceases to 
spread. Then the doses may be diminished or the interval between them 
increased, but the remedy should not be wholly discontinued until con- 
valescence is well established. In many cases this treatment appears to 
arrest the further progress of the disease in three or four days. There are 
some cases in which this preparation of iron is not well borne, or is re- 
jected by vomiting. In such cases I have substituted the sulphite of 
sodium in doses of six decigrams (gr. x), with 0.3 cubic centimetres 
(m. v) of the tincture of belladonna, in solution with mint- water, re- 
peated just as often as in other cases I repeat the iron, and with excellent 
effect. In the epidemic of 1863, I treated some of the worst cases that 
came under my care, both in the hospital and out, with the sulphites of 
sodium and calcium, very satisfactorily. 

It appeared to me slower in developing its effects than the iron, but none 
the less permanent?* If at any time during the progress of an attack of 
erysipelas, diarrhoea supervenes, it can be best controlled by giving the 
emulsion of oil of turpentine and tincture of opium, according to the 
same formulas that I gave you when discussing the treatment of typhoid 
fever. In this city and throughout the larger part of the great interior 
valley of this continent, the local epidemics of erysipelas have been mate- 
rially influenced by the co-existing presence of malaria, imparting to the 
fever a more remitting type, and to the external inflammation a more per- 
sistent disposition to spread. In all cases occurring under such circum- 
stances, the sulphate of quinia should be given in moderate but efficient 
doses, in conjunction with the tincture of chloride of iron or the sulphites. 
In the earlier years of my residence here, when malarious or periodical 
fevers were much more prevalent within the city limits than in recent 
years, I met with such cases of erysipelas, and used quinine as an adjunct 
in their treatment, with the best results. When cases of erysipelas be- 
come complicated with important internal inflammations, such complica- 
tion must be promptly treated by the same remedies that would be indi- 
cated by a similar grade of disease in the same parts under other circum- 
stances. If the meninges of the brain or other serous membranes are 
attacked, accompanied by a high temperature and a firm pulse, one free 
bleeding by venesection in the first stage of its progress, will be found 
promptly beneficial in checking the progress until time is gained for other 
remedies to develop their action. I well recollect a case occurring in my 
practice during the notable epidemic of 1843, in the person of an adult 
male, of rather plethoric habit, and sanguine temperament. The general 
fever was active, and the inflammation attacked the face, spreading rapidly 
over the w r hole face and head, accompanied by much tumefaction and ves- 
ication. On the third day, while the inflammation was extending rapidly 
from the face over the whole scalp, the patient became wildly delirious, 
with contracted pupils, and a corded, tense pulse. I directly opened a 
vein in his arm and let the blood flow from a good-sized orifice, to the extent 
of more than one litre (fl. §xxx), with the most tranquilizing effect. The 
whole subsequent progress of the case was modified, and the patient made 
a good recovery. 

* See Chicago Medical Examiner, Vol. IV, pp. 161-2, 1863. 
11 



162 ERYSIPELAS. 

Thus far I have said nothing in regard to local applications to the in- 
flamed surfaces in erysipelatous fever, simply because I regard them as 
capable of exercising no control over the progress of the disease. When 
I first entered the ranks of the profession, nearly half a century since, very 
much importance was attached to local applications in this disease. It 
was thought that the extension of the inflammation might be arrested by 
deadening the whole inflamed surface with strong applications of nitrate 
of silver, tincture of iodine, strong solution of sulphate of iron, and even 
encircling the inflamed surface with narrow blisters. Others recommended 
the constant application of cold lotions, as solutions of acetate of lead, 
alum, and poultices made of cranberries. 

During the first ten years of my practice, which included the epidemic 
years from 1841-46, I tried all these expedients faithfully, until I became 
fully convinced that none of them exerted any controlling influence what- 
ever over either the local inflammation or the general fever. Conse- 
quently, during the last thirty years I have used no local applications to 
erysipelatous surfaces, except such as were calculated to add to the comfort 
of the patient by lessening the burning pain in the inflamed surface. For 
this purpose, keeping the surface moistened with a lotion made of equal 
parts of glycerine and rose-water succeeds well, and is pleasant to use. 
The next most comfortable application is cloths kept a little wet with a 
cold solution of acetate of lead. 

A few years since, Dr. J. S. Whitmire, of Metamora, 111., reported to 
the Illinois State Medical Society several cases of severe erysipelas, in 
which the disease was speedily arrested by the hypodermic injection of a 
'.few drops of a strong solution of carbolic acid at the margin of the inflamed 
surface. 

It would be necessary to exercise much care in regard to the quantity 
of the carbolic acid introduced into the subcutaneous tissue, or its effects 
might be far more dangerous to the patient than the disease it is intended 
to cure. Throughout the whole course of the disease, proper attention 
should be given to the support of the patient by nourishment. Milk, 
beef-tea, thin wheat flour and milk gruel, and oatmeal gruel, constitute the 
best articles of nourishment. They should be given in small quantities at 
a time, but repeated sufficiently often .to afford a fair degree of support, 
without accumulating too much in the stomach at one time. In those 
comparatively rare cases in which the erysipelatous inflammation develops 
in the fauces, pharynx, and tongue, rendering deglutition difficult or 
impracticable, the nourishment, as well as the medicines, must be admin- 
istered mostly in the form of enemas. In the more malignant and typhoid 
grades of erysipelas, many recommend the free use of wine, brandy, and 
other alcoholic liquids. 

I have seen many bad cases of erysipelas in which the habitual use of 
alcoholic liquids appeared to have been the chief predisposing cause; but 
I have never seen one in which the use of these liquids had any beneficial 
effect, either in sustaining the patient or in curing the disease. 

Prophylaxis. — As the infection or specific cause of erysipelas is capable 
of adhering to clothing, bedding, sponges, instruments, and even the hands 
of the attending physician, great care should be exercised in having all 
such things as have been in contact with an erysipelatous patient thor- 
oughly cleansed and disinfected, before allowing them to be used by others. 
Beds, mattresses, etc., can be most easily and reliably rendered innocuous 
by baking, or heating them to a high temperature in dry air. And, as 
practitioners, you should ever be particularly careful not to carry the infec- 
tion on your hands or instruments to your obstetric patients. Whether 



DIPHTHERIA. 163 

taking daily two or three moderate doses of the tincture of chloride of iron 
or of the sulphite of soda by well persons, during the prevalence of a severe 
epidemic, would prevent their being attacked — on the same principle that 
moderate daily doses of quinine often protect an individual from attacks 
of ague while living in a highly malarious atmosphere — remains to be 
determined by future experience and observation. 



LECTURE XIX. 

Diphtheria.— Its History, Causes, Symptoms, Diagnosis, Prognosis, Pathology, Treatment and 
Sequelae. 

GENTLEMEN: — The word Diphtheria, as used to designate a particular 
form of disease, is of recent origin, having been first applied to that 
purpose by Bretonneau in a valuable paper laid before the French Acad- 
emy of Medicine, in 1821. "While the name is thus modern, the disease 
has been recognized and described, with varying degrees of accuracy, 
from a very early period in medical history. The Grecian writers alleged 
that the disease originated in Egypt, and called it " Malum jEgypticum" 
in the days of Homer and Hippocrates. An epidemic of the disease in 
Rome was recognized and described by Macrobius in the year 380, A. D. 
From that time to the middle of the sixteenth century, I find but few 
allusions to the disease. At the latter date, 1557, it appeared in Holland 
as an epidemic; in Germany, in 1650; in France and Italy, in 1749; and 
in England, from 1760 to 1769. While the descriptions of all these earlier 
epidemics are sufficiently accurate to render it certain that the writers 
were, for the most part, describing the disease now called diphtheria, it is 
equally evident that they often confounded with it scarlet fever and vari- 
ous forms of sore throat. Perhaps the most accurate of the early records 
is, " An Account of the Putrid Sore Throat," as it prevailed in London, by 
Dr. John Fothergill, published in 1769. The earliest account we have of 
this disease in America was written by Dr. Douglass, of the Massachusetts 
Colony, in 1736.* It undoubtedly prevailed in New York in 1771, and 
was pretty clearly described by Dr. Samuel Bard. From that time to 
'1831 we find nothing in the medical literature of our country which could 
be regarded as applying to true diphtheria; although it was more or less 
prevalent on the continent of Europe, and was being carefully investigated 
by Bretonneau, at Tours, from 1818 to 1821. 

Dr. John Bell, of Philadelphia, alludes to the prevalence of an epidemic 
sore throat in that city in 1831, which w T as evidently true diphtheria. In 
1856 the disease prevailed with great severity in San Francisco and the 
adjacent counties in California, and during the next two or three years 
epidemics appeared in various parts of New England, New York, and a 
large number of the Middle and Western States. According to Dr. L. N. 
Beardsley, of Milford, Connecticut, the disease commenced in the adjoin- 
ing town of Orange, among the scholars attending a select school, and 

*See the Practical History of a New Epidemical Eruptive Miliary Fever, with an Angina Ulcus- 
culosa, which prevailed in New England in 1735-36. By Dr. William Douglass, of Boston. 



1G4 DIPHTHERIA. 

with such severity that "fourteen cases out of fifteen, of those who were 
first attacked, proved fatal."* In April, 1858, it made its appearance in 
Albany, N. Y., and caused 167 deaths during the next eight inonths.f The 
disease began to attract attention in this city in 1858, and prevailed with 
considerable severity for three or four successive years. 

During the same period of time, it showed itself more or less prevalent 
in almost every inhabited district of country from the Atlantic to the 
Pacific Ocean, and from the Lakes to the Gulf of Mexico. Ir prevailed in 
localities the most diverse in all their local conditions. Elevated, dry, 
thinly populated rural districts were visited as freely, and often as fatally, 
as the lowest alluvial valleys, or the most densely populated cities. It 
presented every gradation of severity, from fifteen deaths in sixteen 
attacks, as reported by Dr. Beardsley, of Connecticut, to only four deaths 
in one hundred and thirty-three attacks, as reported by Dr. Wm. L. Wells, 
of Milwaukee, Wis.J For additional facts regarding the prevalence of 
this disease during the years intervening between 1858 and 1860, and 
earlier, I refer you to an interesting report on the topography and epidem- 
ics of New York, by Dr. Joseph M. Smith, in the Transactions of the 
American Medical Association, Vol. xiii, p. 251, 1860. From that period 
to the present it is not probable that the disease has been entirety absent 
from all parts of the country for a single year. We find it occupying a 
place of more or less prominence in nearly all the annual tables of mortal- 
ity in our cities, and accounts of its prevalence in some of the country 
districts have come to us every year. It seldom prevails in the same rural 
district more than two or three years in succession, without a period of 
exemption. And in the larger cities it presents its distinct waves of 
increase and decrease. For instance, in Philadelphia the number of 
deaths from diphtheria each year for eight successive years was, in 1872, 
141; 1873,106; 1874,181; 1875,656; 1876,708; 1877,458; 1878,464; 
1879, 321. In this city (Chicago) and in New York, the statistics of mor- 
tality indicate the same wave of increase in 1875, culminating in 1876, 
and receding through 1877-78-79.|| 

Causes. — The predisposing causes or circumstances that appear to 
favor the prevalence of diphtheria, are, childhood and youth; dampness, 
with frequent changes in the thermometric conditions of the atmosphere; 
overcrowding of houses and consequent lack of ventilation; the presence 
of the products of the decomposition of organic matter, whether animal 
or vegetable; and the want of attention to personal cleanliness and do- 
mestic hygiene. 

While it is true, that during the epidemic prevalence of diphtheria, 
persons have been attacked at all periods of life, from infancy to ripe old 
age, very much the larger number of cases occur in childhood. Of the 
133 cases reported by Dr. Wells, 1()7 were in children and 26 in adults. Of 
the latter, one was 63 years of age; while the great majority of the former 
were between the ages of 2 and 10 years. Dr. Willard, of Albany, in 
giving an account of an epidemic in that city, reports 179 deaths, of which 
only three were adults, all the remainder being children, most of whom were 
under twelve years of age. From the statistics of the severe epidemic 
prevalence of this disease in England from 1857 to 1860, it would appear 
that more than 85 per cent, of all the deaths were of children under 

* See Boston Medical and Surgical Journil, 1858. 

fSee Transactions of New York State Medical Society, pp. 182-5, 18:9. 

j See Chicago Medical Examiner, Vol. I. 1860, p. 194. 

|| See Transactions of College of Physicians of Philadelphia, Thi*d Series. Vol. V. p. 38, 1881. 
Also Report of Dr. John F. Nagle, of New York, in National Board of Health Bulletin, for Nov. 
12, 1881, Vol 3, No. 20. 



CAUSES. 165 

the age of fifteen years.* It is probable that seventy-five per cent, of all the 
cases of diphtheria occur in children under twelve years of age. And as 
one attack of the disease does not destroy the susceptibility of* the system 
to subsequent ones, there must be something in the conditions of child- 
hood that acts the part of a predisposing influence. 

While isolated cases of diphtheria occur in particular houses or circum- 
scribed localities at all seasons of the year, and epidemics have occurred 
in all varieties of climate, yet it remains true that the disease, especially 
in epidemic forms, prevails much the most frequent and severe within the 
temperate zone, and during the spring and autumn months, when atmos- 
pheric conditions are most variable. That overcrowding of the population, 
as in the tenement houses in our cities, with neglect of ventilation, and 
the accumulation of vegetable and animal matters from want of sewerage 
and cleanliness, act as strongly predisposing influences, is abundantly shown 
by the behavior of the disease in all our large cities during its special 
periods of prevalence from 1856 to 1860, from 1864 to 1867, and from 1875 
to the present time. For instance, in New York city, during the three 
months ending September 30th, 1881, the whole number of deaths from 
diphtheria was 545 ; of which 405 took place in tenement houses, leaving 
140 to occur in all other dwellings. During the last five months of the 
year 1877, there were reported to the health officer of this city (Chicago), 
162 deaths from diphtheria, occurring in 122 dwellings. The health officer 
caused each of these houses to be very thoroughly examined by an expert 
plumber and sewer builder, whose report showed 13 of these houses to be 
in excellent sanitary condition in every respect; 14 faulty from insufficient 
ventilation only; 19 from insufficient ventilation and uncleanliness; 24 
from insufficient ventilation and uncleanliness, both of persons and prem- 
ises; and 52 from defective sewerage and plumbingf. 

Facts of similar import may be gathered in connection with the preva- 
lence of the disease in all large cities; and they justify the conclusion that 
in such aggregations of population, those persons and families who live in 
poorly ventilated, uncleanly, and imperfectly sewered houses and premises, 
yield a larger proportion of victims of diphtheria, than those in better 
sanitary surroundings. But, as I have already pointed out to you in pre- 
vious lectures, this conclusion is equally, or even more applicable to the 
prevalence of typhoid, typhus, and all other acute general febrile affections 
of kindred type. And, consequently, the only legitimate deduction 
from the facts, is, that the diminished power of vital resistance from im- 
paired tone of health caused by living- in bad sanitary conditions, causes a 
more ready yielding to the influence of the essential cause or causes of 
diphtheria. 

On the other hand, in villages and country districts, the disease has pre- 
vailed in its epidemic form with as much severity and fatality, in propor- 
tion to the population, as in the most densely populated cities; and in 
such districts it has shown little or no preference for the poor or uncleanly, 
but has invaded dwellings kept in the most perfect sanitary condition, and 
rural districts usually deemed most healthy. For instance, Dr. William 
C. Wey, of Elmira, N. Y., after carefully noting the rise, progress and 
decline of an unusual prevalence of diphtheria in that place during the 
years 1877-78-79-80, says: " In the epidemic which has so severely visited 
Elmira, the questions of filth and water-supply from unclean sources, as 
means of inducing and spreading the disease, have been carefully consid- 
ered. In some cases the water-supply has been found corrupted; in many 

*See Reynold's System of Medicine. Am. Edition. Vol. I, p. 62. 

t See Report of Department ot Health of the City of Chicago, 1876-7, p. 15. 



1G6 DIPHTHERIA. 

the general surroundings have been unsanitary, and the facilities and com- 
forts of the sick and attendants limited and unsatisfactory. As a matter 
of course, great mortality has followed in the train of neglect and poverty. 
In other cases the water supply has come from pure sources, the sanitary 
conditions of the people and their manner of living have been faultless, 
the utmost watchfulness has been exercised to maintain rigid non-inter- 
course with seats of the disease, and yet, in spite of care, and as if in 
defiance of it, the affect. on has appeared with as much malignity as in 
places of human crowding and disregard of hygienic precautions."* 

These are the statements of one of the most experienced and intelligent 
practitioners in that State. To precisely the same import are the facts given 
by Dr. N. B. Bailey, of Brewster, Putnam County, N. Y., in an account 
of an epidemic of diphtheria that prevailed in that place during the years 
1877-78, published in the same volume of Transactions from which I have 
just quoted. My own personal observations lead to the same conclusions. 
I have met with the disease here, in this city, in all grades of severity, 
among both rich and poor, in the stateliest mansions of luxury, and in the 
most narrow, dark, damp and uncleanly hovels of poverty and vice. It 
has visited, from time to time, almost every county in this and neighboring 
States, and has proved as malignant and fatal, in proportion to the popu- 
lation, on the open plains, and thinly populated, healthy, rural districts in 
Northern Illinois, Wisconsin, and Minnesota, as in the most unsanitary 
wards in the city of Chicago. At most, therefore, bad sanitary conditions 
can only be regarded as predisposing influences, and we must look in 
other directions for the efficient cause or causes on which the disease 
depends. 

Many of the most eminent observers and writers of the present time 
represent the essential cause of the disease to be a specific contagium 
vivum, or organic germ, which has been shown to exist abundantly in the 
diphtheritic exudation or membrane, and in the epitheiial layer of the 
membrane lining the fauces and other parts affected by the local manifes- 
tations of disease. By some, this organic germ is claimed to be the 
"Oidium Albicans," a fungus, consisting of sporules or micrococci and 
mycelium.'!; In 1868 Buhl, Hueter, and Oertel, discovered in the diphthe- 
ritic membranous formations, and in the mucous membrane covered by 
them, various species of bacteria, the most important of which were an 
exceedingly minute spherical variety, called by Cohn, micrococcus, and the 
bacteria termo, or rod-shaped bacteria. J By Oertel, and many others, 
these minute organisms are regarded as the essential cause of the diphthe- 
ritic disease, and they claim to have produced well characterized diph- 
theria in animals by inoculation with portions of the membrane from the 
fauces. 

On the other hand, the results of the experiments of Burden-Sanderson, 
with filtered liquids; the failure of Trousseau and Peter, to induce the 
disease in themselves by the very free application of the membranous 
substance to their own fauces; and the entire failure of Curtis and Satterth- 
waite, and H. C. Wood and Formad, to induce the disease in animals 
by repeated and carefully executed inoculations with diphtheritic matter, 
go far to disprove the conclusions of Oertel and his followers. And if we 
add to these the further fact that every variety of germs found either in 
the membranous exudations of diphtheria, or in the blood and tissues of 
diphtheritic patients, have also been found in the miguet or curdy exuda- 

*See Transactions of the New York State Medical Society for 1881, p. T43. 

fSee Clinical Lecture by Dr, i-aycock, of Edinburgh, in 1858. 

jfc'ee Cyclopaedia uf the Practice of Medicine, by Ziemssen, Vol. I,' p. 588. 



SYMPTOMS. 167 

tions upon the mucous membrane of the mouth and fauces in young chil- 
dren, in the white exudations upon the tonsils and fauces in the last stage 
of consumption and other wasting diseases, and in the exudations that 
sometimes appear on different parts of the mucous membrane in typhoid, 
typhus, and other low forms of fever, we shall find it much more in accord- 
ance with sound principles of reasoning to conclude that these minute 
organic forms, called bacteria, micrococci, etc., are simply accompaniments, 
if not products, of certain degenerative organic processes that take place, 
to a greater or less extent, in all the acute febrile and inflammatory affec- 
tions of an asthenic type. If we adhere impartially to well ascertained 
facts, we must admit that diphtheria often makes its appearance in families, 
asylums, and schools, as well as at the beginning of epidemics, under such 
circumstances that it is impossible to trace it to any form of communica- 
tion with previous cases, either in the same localities or elsewhere. In 
other words, it is capable of spontaneous development, and consequently 
does not depend for its production and spread upon any specific conta- 
gious germs or virus generated in the bodies of the sick. I have seen 
many cases illustrative of this fact; and the same is strikingly exemplified 
by the outbreak of the disease in Brewster, N. Y., as described by Dr. 
Bayley, in 1878* 

The same adherence to simple facts, however, compels us to admit that 
in very many cases the disease appears to spread by an infection capable 
of contaminating clothes and furniture, and of being carried by them from 
family to family, and from one locality to another. Oertel recognizes both 
these series of facts, and claims that when it develops spontaneously, it is 
from some organic miasm y and hence he includes diphtheria in his class 
of "-miasmatic contagious diseases." The fact that this disease usually 
prevails as an epidemic, commencing often without any traceable commu- 
nication with previous cases or known contagious influence, and attacking, 
simultaneously, members of families in different parts of a city, village, or 
rural district, ".vho have neither had any communication with each other 
nor with any known common source of infection, would indicate that its 
essential cause consists in some special condition of the atmosphere, which 
the older writers called an epidemic constitution. Its nature will remain 
unknown until more systematic and continuous observations are made and 
recorded, concerning all appreciable conditions of the atmosphere in direct 
connection with records of the prevalence of acute general diseases. 
When this is done through a series of years, with the accuracy now attain- 
able by the aid of physics, chemistry, and microscopy, we shall have such 
elements for comparison as will throw light upon this and many other 
obscure questions connected with the etiology of diseases. 

Symptoms. — For the clinical study of diphtheria I shall group the vari- 
ous cases met with, under three heads — namely : the simple, the croupous, 
and malignant. In the first group I shall include all the cases that pre- 
sent so moderate a degree of severity as to pass through their successive 
stages with a natural tendency to convalescence. In the second group I 
shall include all those cases in which the local inflammation invades the 
larynx and trachea. In the third group will be included all such cases as 
by the gravity of the general morbid conditions, or the severity of the 

* See Transactions of the New York Stat? Medical Society for 1881. p. 345.— Dr. Bayley says: " In 
nventy-one of the fifty cases of which I have notes, the disease was developed without any known 
previous exposure ; and especial pains were taken to arrive at the truth. In seven of these cases 
there could be no mistake, as they were the primary ones, and no members of these families (three 
in number) had been exposed to any sore throat whatever. Moreover, these seven fell iL on the 
same days, viz.: December 2d, 3d, and 4th ; and at two different points, separated by a distance ot' 
3,218 kilometers (nearly three miles) ; and, further, the families moved in very different spheres, 
and did not come in contact with each other in any manner." 



168 DIPHTHERIA. 

nasopharyngeal and glandular inflammations tend strongly towards a fatal 
result. The majority of cases of simple diphtheria are developed grad- 
ually; the patient feeling for one, two, or three days a gradually increasing 
sense of weariness; indisposition to mental or physical activity; vague or 
ill-defined pains in the head, back, and limbs; with indifference to food. 
Then the face becomes a little flushed, the lips dry, the expression of coun- 
tenance dull, the pulse moderately accelerated, with an increase of one or 
two degrees of temperature, and a more decided sense of weakness; and, 
in addition to these symptoms of a moderate general fever, there is observ- 
able a little undue fullness behind and beneath the angle of the jaw, with 
some feeling of stiffness and soreness in swallowing. On examining the 
fauces at this stage you will find the mucous membrane covering the ton- 
sils, arch of the palate, and portions of the pharynx, presenting a tumefied 
and dark red appearance, with some spots of white, or yellowing white, 
membranous exudation closely adhering to it, together with some degree 
of swelling of the tonsils and neighboring lymphatic glands. 

In a smaller number of the cases belonging to this group, the attack is 
more abrupt, and accompanied by chilliness or even a decided chill, fol- 
lowed by a more active general fever, but the same local symptoms as I just 
described. The symptoms thus begun usually gradually increase during 
the succeeding three or four days. The patches of membrane on the 
inflamed surface of the fauces increase in number and size, until in many 
cases they coalesce and cover nearly the whole surface, and extend with the 
inflammation into the posterior nares. During the same time the tonsils 
and lymphatic glands also increase in size, impeding the free opening of 
the mouth, and rendering deglutition more difficult. The fauces also become 
troubled with an excess of tenacious mucus, which in young children 
often causes much rattling in the throat and some cough. The urinary 
secretion is moderately diminished, and in a small proportion of cases con- 
tains some albumen, and the bowels usually remain quiet unless disturbed 
by laxative medicine. 

This class of cases usually reach the climax of activity in both general 
and local symptoms in from three to five days after the first development 
of local symptoms. The swelling of the glands of the neck and parts 
within the fauces ceases to increase; the membranous exudation soon 
appears more yellow and shows signs of loosening or disintegration; the 
saliva or mucus in the mouth and fauces becomes more opaque, more easily 
dislodged, the breath more offensive, and generally some discharge from 
the nostrils. While these local changes are taking place, the general 
febrile symptoms also diminish ; and in the mildest variety of cases b}^ the 
end of the first week, the temperature has returned to the natural standard, 
the pulse becomes soft and weak, but natural in frequency; the cutaneous 
and urinary secretions natural, and the membranous exudation and swell- 
ing both in the fauces and lymphatic glands disappear, leaving the patient 
fairly convalescent, yet much debilitated. In the more severe cases belong- 
ing to the first group, the morbid phenomena reach their climax in the same 
length of time, and the same subsequent changes take place, but the sub- 
sidence of the glandular swellings and the disintegration of the membran- 
ous exudations progress slower, and are accompanied by more copious and 
troublesome discharges from the mouth and nostrils, and greater offensive- 
ness of the breath. The patient also exhibits more dullness, with paroxysms 
of restlessness, especially when the fauces and nostrils become obstructed 
by the mucous or muco-purulent discharge, as is apt to be the case in 
infants and young children. The pulse becomes more weak, the bodily 
temperature returns more slowly to the natural standard, although the skin 



SYMPTOMS. 169 

and extremities may even feel unduly cold, and the patient is longer 
troubled with difficulty of deglutition, and more tendency of food and 
drink to regurgitate through the nostrils. Yet, in nearly all of these cases 
the disease completes its course, and convalescence is established by the 
middle or latter part of the second week. In some, however, the breaking 
up and disappearance of the false membrane is accompanied and followed 
by superficial ulcerations in the tonsils and other parts of the throat; and, 
in a smaller number, one or more of the inflamed lymphatic glands suppu- 
rate, forming abscesses in the neck. These occurrences may postpone the 
establishment of convalescence until some time during the third week 
from the commencement of the attack. 

The second or croupous group of cases, including all those in which the 
diphtheritic inflammation invades the larynx, will be presented to you under 
two aspects : one, in which the inflammation enters the larynx apparently 
by extension from the pharynx, and generally manifests itself first between 
the fourth and seventh days after the commencement of the disease, or 
even after convalescence has fairly commenced; the other, in which the 
inflammation attacks the larnyx primarily, giving rise to hoarseness of 
voice, stridulous breathing and croupal cough, from the beginning of the 
patient's sickness. In both, the general symptoms are the same as in 
ordinary diphtheria. 

In all the cases in which the local disease develops in the larynx by 
extension from above downward, and does not commence until several 
days after the beginning of the general diphtheritic disease, there can be 
no difficulty in making the diagnosis. But when the larynx is invaded 
coincidently with the beginning of the sickness, there is often much diffi- 
culty in keeping a clear line of distinction between the diphtheritic 
disease and the ordinary sporadic pseudo-membranous laryngitis. And 
many writers of the present day regard them as identical, and do not 
attempt to distinguish the one from the other. In all the cases that have come 
under my observation, however, the diphtheritic laryngitis has been accom- 
panied by some redness and swelling of the tonsils and other glands in 
the neck; a soft, weak pulse; more dullness of expression, and earlier 
symptoms of exhaustion. In all these cases the inflammation in the larynx 
is accompanied by a rapidly increasing exudation, which solidifies into a 
thick, firm layer of false membrane Over all the interior of the larynx, the 
cartilages at the opening of the glottis, and often downward through the 
treachea and into the larger bronchial tubes. The voice becomes early 
suppressed, the cough rough, stridulous and suffocative; the breathing 
difficult, and accompanied by a tight, wheezing sound in the neck at first, 
but subsequently accompanied by mucous rattle. To these local symptoms 
of direct obstruction in the larynx, there is added a soft, quick, weak pulse, 
somewhat purplish or leaden color of the lips, and fullness or bloating of the 
face; coolness of the extremities, with moderate increase of temperature in the 
head and trunk of the body; drowsiness, with temporary paroxysms of 
restlessness and tossing; often difficulty of deglutition, and scantiness 
of urine. In very severe cases the dyspnoea and rattling in the throat 
and larynx increases every hour, with frequent paroxysms of choking, 
strangling cough, during which, more or less of a thick, ropy mucus is 
forced out, containing shreds of the false membrane; after which, for a 
brief time, the breathing is easier. But the obstruction soon accumulates 
again, causing the sense of suffocation and struggling lor breath to be 
renewed, until the imperfect oxygenation and decarbonization of the blood 
renders it no longer capable of sustaining the sensibility of the brain and 
nervous centers, when the patient becomes somnolent or stupid, the 



170 DIPHTHERIA. 

breathing frequent, very difficult, and accompanied by coarse mucous rat- 
tling in the air passages; blueness of the lips; coldness and blueness of 
the extremities; a small and very weak pulse; and, finally, relaxation of 
the sphincters, a general clammy sweat, and death from asphyxia. The 
fatal result is reached in some of these cases in five or six hours; in a 
much larger number, however, it is deferred from two to five days. If the 
tumefaction of the parts within the larnyx and the membranous formations 
are not sufficient to destroy life in from three to five days, the latter begin 
to loosen and disintegrate, and in the paroxysms of coughing more shreds 
and patches of the membrane are dislodged and thrown out with a more 
opaque, muco-purulent expectoration. 

The tightness and constriction in the breathing diminishes; the color of the 
skin and expression of countenance improve; the pulse becomes slower; 
the mind more active; and in three days, or from seven to nine from the 
commencement of the laryngeal trouble, all bad symptoms have disap- 
peared, leaving the patient convalescent but much debilitated. In some 
cases of diphtheritic laryngitis, the membrane is detached and thrown out, 
in the severe paroxysms of coughing, in large pieces, presenting, when 
inflated, more or less of a complete model of the interior of the larynx. 
Many years since I saw a case in consultation with my colleague, Dr. 
Hollister, in which the patient, a boy aged seven years, in a violent par- 
oxysm of coughing expelled a perfect tubular cast of the larynx and tra- 
chea, measuring seven inches in length to the bifurcation, and extending 
beyond to the primary division of the bronchial tubes, having thirteen divis- 
ions on one side and eleven on the other.* The expulsion was followed 
by a great degree of immediate relief; but, as frequently happens, the 
relief was only temporary. Fresh exudations took place on the inflamed 
membrane, and, extending lower into the bronchial tubes, renewed the 
dyspnoea, and proved fatal before the end of the next twenty-four hours. 

In the third, or malignant group of cases, the onset of the attack is gen- 
erally abrupt, and attended by appearances of a chill or cold stage, which 
is followed by a more rapid rise of temperature of the body; a more rapid 
development of inflammation and swelling, both in the fauces and glands 
of the neck, often causing in a very few hours great difficulty of deglu- 
tition, inability to open the mouth widely, and the speedy formation of a 
thick, tough, yellowish membrane over the whole arch of the palate, ton- 
sils, and pharynx. The pulse is frequent, soft, and weak; breathing noisy 
from the existence of tenacious mucus in the throat and nostrils, and more 
frequent than natural; the expression of countenance dull, with a dark or 
purplish flush; extremities often cool, with leaden color under the nails; 
urine seanty, and often containing some albumen; and the mind inclined 
to drowsiness, except in momentary paroxysms of restless tossing or of" 
efforts to clear the mucus from the throat. Sometimes the attacks of this 
variety are so severe, and the tumefaction of the tissues within and behind 
the angle of the jaw so great, that the blood is obstructed in its return 
from the brain, causiug stupor, inability to swallow, extreme frequency 
and feebleness of pulse, and death in from twelve to eighteen hours after 
the beginning of the attack. In other cases, the obstruction to the cere- 
bral circulation is less, and life is prolonged from one to five days. In 
such, during the second day, the inflammation and exudation extend into 
the nostrils posteriorly, and sometimes into the eustachian tubes, and even 
into the middle ear. During the third and fourth days the false mem- 
branes begin to disintegrate, the mucus in the fauces and nostrils becomes 
more abundant, more opaque or muco-purulent, decidedly offensive, and 

♦See Chicago Medical Examiner, Vol. I, pp. 95-6, 1860. 



DIAGNOSIS. 171 

(rive? occasion to much noise and difficulty of breathing. The inflamed 
mucous membrane also shows commencing ulceration, and in many cases 
gaugrene. The patient loses strength rapidly, and usually dies from com- 
plete exhaustion before the end of the fifth day. 

I have now given you a summary of the more important symptoms of 
the different grades of diphtheria. You observe that it is a disease vary- 
ing- greatly in its degree of severity in different seasons, and in different 
cases the same season. So true is this, that I have in some years attended 
a large number of cases with less than two per cent, of deaths; while in 
other years, with no greater numbers, the proportion of croupal and malig- 
nant cases was so great that the deaths averaged from ten to fifteen per 
cent. It is not rare that, in the more severe epidemics of this disease, all 
the children in a family are destroyed within a few days. I remember 
being called to visit, in consultation, a Scandinavian family in the north- 
west part of the city, wdiere I found three children lying side by side on 
the same table, dressed for burial, and a fourth one dying, leaving only 
the nursing in tan t in its mother's arms. 

Thus far I have spoken of the diphtheritic membranous exudations as 

appearing only in the throat and parts in immediate connection with it. 

The same, however, may attack the vagina and vulva, the lips, the wing 

of the nose, the conjunctiva of the eye, and any sore or raw surface 

in any part of the body. I saw one well marked case, in which a thick 

layer of false membrane covered one-third of the upper lip, accompanied 

by considerable tumefaction: and another in which a lady, recovering from 

an extirpation of a cancerous tumor from one breast, while there was still 

a healthy granulating surface unhealed, was attacked with the ordinarv 
•■ ~ ~ . . . . ■ 

general symptoms of diphtheria, accompanied with a moderate degree of 

inflammation and exudation in the fauces. Simultaneous with the appear- 
ance of the latter, the uncicatrized surface on the breast became com- 
pletely covered with a thick layer of false membrane, which remained 
about three days, and as it disintegrated and disappeared, it was accom- 
panied by an abundant sero-purulent and offensive discharge, with a com- 
plete destruction of all the previously healthy granulations. Alter the 
diphtheritic disease had disappeared, the raw surface on the breast gradu- 
ally resumed a healthy appearance, and subsequently progressed to com- 
plete cicatrization. 

Diagnosis* — From catarrhal sore throat, diphtheria is distinguished by 
the character of the general fever; the coincident inflammation of the 
mucous membrane of the fauces and tonsils, with tumefaction of some of 
the lymphatic glands near the angle of the jaws; and still more, by the 
appearance of more or less diphtheritic exudation on some part of the 
inflamed structures. The diagnostic differences between diphtheria and 
ordinary sporadic croup or active pseudo-membranous laryngitis, I pointed 
out when giving the symptoms of the croupous variety of diphtheria, and 
need not repeat them. From scarlet fever, diphtheria is distinguished by 
the much less sudden and severe onset of the fever, the presence of diph- 
theritic membranous exudations, and the absence, generally, of any exan- 
thematous eruption upon the skin. In some epidemics of diphtheria quite 
a proportion of the cases will be accompanied by a moderate amount of a 
fine red exanthematous rash, causing the surface to much resemble mild 
cases of scarlet fever. But the milder grade of general fever, and the 
coincident existence of white patches of diphtheritic membrane in the 
fauces, will usually enable the practitioner to keep the diagnosis correct. 
It has undoubtedly happened, however, when both these general febrile 
diseases were prevailing in the same community, that they have manifested 



172 DIPHTHERIA. 

a disposition to commingle the characteristic symptoms of both in the 
same patient, thereby causing doubt and sometimes controversy concern- 
ing the diagnosis. It is more proper to regard such cases as presenting 
the combined or simultaneous presence of the causes of both diseases, in 
the same manner as we recognize the coincident action of the causes of 
typhoid and periodical fevers, producing what has been styled typho- 
malarial disease. 

Prognosis. — The prognosis has been pretty fully indicated by the clin- 
ical history I have just detailed to you. All the milder cases tend towards 
spontaneous recovery in from seven to fourteen days. The more malignant 
and the croupous groups of cases manifest a strong tendency to end in the 
death of the patient, and are always productive of a high ratio of mortality. 

Pathology. — I regard diphtheria as a general febrile affection, arising 
from some cause or combination of causes by which the properties of the 
blood and of the organized structures are so changed as to render the 
fibrin more disposed to solidify or coagulate than natural, and to lessen the 
tone and contractibility of the muscular structures, with special tendency 
to develop asthenic inflammation of greater or less severity in the mucous 
membrane of the throat and adjacent lymphatic glands. That the general 
disease is one of a typhoid or adynamic character, and the local inflamma- 
tions asthenic, is proved by the generally soft, compressible pulse, universal 
muscular weakness, liability to syncope from moderate exertion, and the 
aplastic character of all exudations. By the latter I mean the uniform 
tendency of all the membranous exudations, however thick or tough they 
may be, to undergo degeneration and dissolution, never taking on perma- 
nent organization or becoming a bond of union by adhesively uniting sur- 
faces that may be in contact with each other. This view is further 
corroborated by the frequent occurrence of muscular paralysis as a sequel 
of the disease. 

Treatment. — From these views of the pathology of diphtheria I deduce 
four well defined, rational indications to be fulfilled by treatment: First, 
to arrest the further infection and deterioration of the blood. Second, to 
improve the general tonicity of the tissues by increasing the vital affinity. 
Third, to sustain the nutritive and excretory functions as near their natural 
condition as possible. Fourth, to mitigate the violence of such local inflam- 
mations as may exist in each individual case. To fulfill the first of these 
indications, the chief reliance has been placed on the internal use of chlo- 
rine, bromine, iodine, and their salts, such as the chlorates of potassium 
and sodium; and to these have been added more recently, the sulphurous 
acid and the sulphites of sodium and calcium,the benzoate of sodium, 
the sulpho-carbolate of sodium, and the permanganate of potassium. Of 
these, I think the aqueous solution of iodine, the chlorate of potassium 
and the benzoate of sodium are the most important. To fulfill the second in- 
dications, I rely principally upon a judicious use of quinia, iron, strychnia, 
pure air and nourishment; even when temporary stimulants are needed, car- 
bonate of ammonium and camphor are the most reliable. Many recommend 
strongly the use of some one of the alcoholic class of drinks, and mention 
the extraordinarily large doses borne by diphtheritic patients without intoxi- 
cating effects. So far is this from affording a reason for their use, that I 
should construe it in the opposite direction. Both the general susceptibility 
of the tissues and the sensibility of the nervous system are blunted or 
below the normal standard, and consequently, anaesthetics like alcohol, are 
neither indicated nor readily responded to when given. The same prin- 
ciple or therapeutic rule applies here,, that I explained more fully when 
speaking to you in relation to the treatment of typhoid fever. 



TREATMENT. 173 

If vou can succeed well in fulfilling* the first and second indications as 
now explained, the fulfil. ment of the third follows as a necessary result. 
Yet, when called early, and you find the skin hot and dry; urine scanty; 
tongue coated; and bowels inactive, you can give a small alterative dose 
of calomel with bicarbonate of sodium, every three or four hours, until 
three doses are taken; and if the bowels do not move in three hours after 
the third dose, give a mild laxative, and it will generally produce a favor- 
able effect. The action of the skin and kidneys may be further sustained 
by suitable doses of spirits of nitrous ether and liquor ammonii acetatis. 
To fulfill the fourth indication, namely — to lessen the severity of the local 
inflammation in the fauces, air passages, and glands of the neck, a great 
variety of local applications have been used. During the severe epidem- 
ics in this country, occurring between 1856 and 1864, nitrate of silver in 
all gradations of strength, from the solid stick to a solution of 0.33 grams 
(gr. v.) to 30.0 cubic centimeters (fl. |i.) of water, was extensively and 
perseveringly used locally, with the expectation of arresting the mem- 
branous exudation and of limiting the extent of the inflammation. After an 
abundant experience, its use was abandoned by nearly all the more ac urate 
observers as either useless or positively injurious. Applications of strong 
solutions of sulphate of copper, tincture of iodine, and tincture of the 
chloride of iron, were tried with no better results, and the profession gen- 
erally had come to regard local applications of any kind as a matter of 
secondary importance, until Oertel and others again promulgated the doc- 
trine that diphtheria is primarily a local disease, produced by the direct 
action of bacterial germs on the mucous membrane of the fauces and air 
passages, and through which they entered the blood, and secondarily, pro- 
duced general infectious fever. Under this teaching the early and thor- 
ough local application, not of caustics, but of strong antiseptics or germi- 
cides, as carbolic, salicylic, benzoic, and sulphurous acids, were brought 
prominently to the notice of the profession, and received the unqualified 
commendation of many practitioners. During the past ten or twelve years 
diphtheria has prevailed with average severity in most of our large cities 
and in many country districts, affording abundant opportunities for test- 
ing the virtues of this class of remedies. And, aided by the coincident 
extravagant ideas in regard to the uses of antiseptics in the practice of 
medicine and surgery generally, they were enthusiastically applied in 
every form, and every degree of strength; in solution, with the swab and 
the syringe; in spray, with the atomizers; and in vapor, by inhalations. As 
might be expected, the results, as reported at the various medical society 
meetings and through the medical press, have been varied. As a general 
jule, those who met the disease in a mild form reported great success. 
Those who met the disease in its more severe and malignant aspects, 
reported the usual ratio of mortality, and pronounced the germicide 
treatment useless. A middle class of practitioners, like a member of the 
Illinois State Society, reported, with enthusiasm, that the thorough appli- 
cation of pretty strong solutions of carbolic acid had aborted every case 
that had come under his treatment before the inflammation and exudation 
had entered the posterior nares or the larynx. But unfortunately the dis- 
ease had extended beyond these limits in so many cases before coming 
under treatment, that the actual ratio of mortality to the whole number of 
cases treated, was the same as usual. 

So, gentlemen, if you will diligently examine the statistics of cases and 
mortality in all the cities and municipalities in which such statistics have 
been kept, for the past ten years, in which germicidal theories and prac- 
tice have predominated, with the same class of statistics for the preceding 



174 DIPHTHERIA. 

ten years, you will find no evidence that such practice has resulted in 
diminishing, in any degree, the ratio of mortality below that of the former 
decade. Having already stated to you that I regard diphtheria as prima- 
rily a general febrile affection, developing certain local inflammations of 
peculiar character during its progress, and having now explained the sev- 
eral objects to be accomplished in its treatment, it only remains for me to 
indicate more definitely which of the remedies mentioned for the several 
purposes I deem best, and their mode of use as adapted to the several 
stages of the disease. In the milder cases of simple diphtheria, very little 
medication is either necessary or proper. For such, I direct a diet of 
milk and farinaceous articles, rest, as iresh good air as possible, a moder- 
ate, comfortable temperature of the room, and the following prescription 
for medicine: 

Ijt, Potassii Chlorate 10.0 grams. 3iiss 

Acidi Muriatici 4.0 c. c. 3i 

Tincturas Belladonnae 10.0 c. c. 3iiss 

Aquae 260.0 c. c. § viii 

Mix. Give from two cubic centimeters (fl. 3ss.) to eight (fl. 3ii)» or from 
half a teaspoonful to a dessert spoonful, according to the age of the 
patient, every two or three hours, without further dilution. The applica- 
tion of this solution to the fauces and throat, is made much more complete 
and easy by swallowing it, than by any process of swabbing, sponging or 
gargling; while its introduction into the system constitutes one of the best 
means for fulfilling the first indication for general treatment. The solution 
of the chlorate of potassium with the mineral acid, combines the properties 
of an efficient antiseptic and tonic, while the influence of the belladonna 
on the vessels of the mucous membrane and glands of the throat and neck 
tends to lessen both tumefaction and membranous exudation. 

During the last thirty years I have treated very many cases of mild 
diphtheria, without any other medication than the use of the formula just 
given. If. at any time during its use, the effects of the belladonna accu- 
mulate sufficient to perceptibly dilate the pupils, the dose should either be 
diminished or given at longer intervals. In cases of greater severity, yet not 
positively malignant, I give the same formula in the same manner during 
the first three days after the commencement of the disease. If the patient 
has been previously healthy and well nourished, and the pulse and tem- 
perature rise pretty actively, with scantiness of secretions, I give in addi- 
tion during the first day, an alterative dose of calomel at intervals of once 
in two or three hours until three doses have been taken; and, if nec- 
essary, follow them by a mild laxative or warm water enema. After 
the bowels have moved, I direct a solution of iodine 0.33 grams (gr. v.) 
and iodide of potassium 2.0 grams (gr. xxx.) in 45 cubic centimetres 
(§jss) of water, to be given in doses suited to the age of the patient, 
every six hours. During the same early stage, if the tonsils and glands 
behind and below the angle of the jaw commence to swell actively, I keep 
the external parts closely covered with cloths wet in an infusion of aconite 
leaves and chloride of ammonium, 30 grams (3J) of the former, and 
15 grams (§ss.) of the latter to one litre (Ojj) of boiling water. When, 
from any cause it may be difficult to keep the wet cloths applied properly, 
the following liniment may be used instead: 

# Olei Olivce 90.0 c. c. giii. 

Olei Terebinthinse 15.0 c. c. §ss. 
Chloroformi 15.0 c. c. ^ss. 



TREATMENT. 175 

Mix, and apply to all the external swollen parts every three hours, or 
often enough to keep the surface moist. If, under the remedial agents I 
have now mentioned the case progresses favorably, and when the time for 
the m jmbranous exudations to begin to loosen and disintegrate comes, 
which is generally from the third to the fifth day, the breath and saliva 
do not become offensive, and the swelling of the glands does not increase 
further, there need be no essential change in the treatment except to lessen 
the frequency of doses as the disease declines, and an early convalescence 
will be reached. But if, at the stage just mentioned, the breath becomes 
oifensive, the saliva more abundant, and mixed with more or less muco- 
purulent or sanious discharge from the throat and nostrils, with more dull- 
ness of expression and a softer pulse, I immediately exchange the chlorate 
of potassium and belladonna solution for the tincture of chloride of iron 
and quinine, given in moderate, but frequently repeated doses, and require 
more diligence in giving nourishment. The solution of iodine may gener- 
ally be given with benefit two or three days longer. Under the influence 
of the quinine, iron, and simple nourishment, the patient will pass the 
crisis of the disease with only a moderate amount of ulceration and suppu- 
rative action in the inflamed membranes, and the general febrile symptoms 
will gradually decline until convalescence is established. In some of the 
more severe and malignant cases, the crisis of the disease is marked by 
great weakness, a more copious flow of offensive muco-purulent matter from 
the mouth and nostrils, and more extensive destruction of the inflamed struc- 
tures by ulceration, and sometimes by gangrene. In such cases, I continue 
the use of the quinine and iron, and, in addition, give carbonate of ammo- 
nium and camphor, in moderate but frequently repeated doses, and add to 
what nourishment is taken by the mouth, the use of nutritive enemas. 
Unfortunately, in many of these bad cases, deglutition is so impaired that 
neither medicines nor nourishment can be swallowed in sufficient quantity 
to effect the needed support. Even in such, much can be done to sustain 
them until the throat begins to improve, by a judicious use of milk, beef 
tea, and other items of nourishment in the form of enemas, and most of 
the medicines required can be added to the enemas. Further support may 
also be given by inunction of cod-liver oil, in which may be suspended a 
small amount of strychnine. To a litre (Oii.) of cod-liver oil may be added 
0.2 grams (gr. iii) of strychnine. This may be well shaken and applied 
sufficient to anoint nearly the whole surface of the body three times a day. 
In the cases that present a strongly malignant aspect from the beginning, 
I give the quinine and tincture of chloride of iron, alternated with the car- 
bonate of ammonium and camphor at once; and during the first twenty-four 
hours apply freely over the trunk of the body the cod-liver oil, holding in 
solution a small proportion of iodine; and, after the first day, the strych- 
nine my be added in the proportion already stated. 

During the last few years, I have used a solution of the benzoate of 
sodium as a substitute for the chlorate of potassium, and belladonna solu- 
tion, in the early stage of the disease. Ten grams (3iiss.) may be 
dissolved in 120 cubic centimetres (fl. |iv) of water; of which four cubic 
centimetres, or one teaspoonful may be given to an adult every two hours. 
It appears to exercise much influence in limiting the amount of the mem- 
branous exudation, and is particularly well adapted to the early stage of 
the more active sthenic class of cases. Again, in the second stage of the 
disease, if the muco-purulent discharge from the nostrils becomes copious 
and offensive, or irritating to the parts with which it comes in contact, it 
will do good to have the nostrils syringed out freely at least twice in the 
twenty-four hours, with a weak solution of carbolic acid and sulphate of 



176 DIPHTHERIA. 

zinc or of permanganate of potassium. If an anodyne is required at night to 
aid in procuring rest, I know of none better than a powder containing the 
compound powder of opium and ipecac, 0.33 grams (gr. v) and pulverized 
gum camphor 0.13 grams (gr. ii.) for an adult, and proportionately less for 
children. 

I have now given you an outline of that course of treatment of the 
several stages and grades of severity of this dis< as >, which has been, in 
my hands, the most beneficial to my patients, leading to the highest ratio 
of recoveries and leaving the smallest ratio of important sequelae. One 
variety of cases, however, has been omitted from this outline, namely, the 
croupous or laryngotracheal. When the diphtheritic inflammation in- 
vades the larynx, whether primarily, with the beginning of the attack, or 
secondarily, by extension from the pharynx, I give, as early as possible, 
an emetic dose of the sub-sulphate of mercury, and repeat it at intervals 
of from two to six hours, until the stage of increasing exudation has passed. 
Thirteen centigrams (gr. ii.) of the sub-sulphate given in the form of pow- 
der, will generally produce prompt and free vomiting in children from 
three to five years of age. For older patients the dose should be increased, 
and for younger ones diminished. In the interval between the emetics, I 
give during the first twelve hours, a small dose of calomel and bicarbonate 
of sodium every two hours. To children from three to five years old, six 
centigrams (gr. i.) of calomel and twelve centigrams (gr. ii.) of the 
sodium, may be given at a dose. During the same period of time, a solu- 
tion of lactic acid, 0.33 cubic centimetres (min. v.) to 30. c.c. (fl. |i.) of 
water should be frequently thrown into the fauces in the form of spray 
from an atomizer, and the liniment I have previously mentioned, containing 
oil of olive, oil of turpentine and chloroform, applied freely to the front and 
lateral parts of the neck externally. After the first four or five doses of 
the calomel and sodium have been given, they are omitted, and I give, 
instead, a solution of lactate of iron, 4 grams (3i.) to 120 cubic centimetres 
of water (fl. Jiv.) of water, of which 2 c.c. (fl. 3s3.) or half a teaspoonful, 
may be given every two hours. If the invasion of the larynx has been 
secondary, several days after the commencement of the general disease, I 
omit the calomel and sodium powders, and commence the use of the solu- 
tion of the lactate of iron, alternated with quinine, at once. In all other 
respects their management is the same as I have just indicated. 

Sometimes a mild anodyne and expectorant influence is needed to 
lessen the violent spasmodic quality of the cough and aid in promoting 
rest — especially in the later stages of the disease. For such purpose I 
know of nothing better than an equal mixture of the compound syrup of 
squills and camphorated tincture of opium, given in doses suited to the 
age of the patient. If a judicious use of the remedies I have just detailed 
should fail to relieve the patient, and suffocation be impending, the only 
alternative is a resort to tracheotomy, which almost always affords a sur- 
prising degree of temporary relief, but is very generally followed by an 
extension of the inflammation into the bronchial tubes and the ultimate 
death of the patient. During all the treatment of the croupous cases the 
temperature of the room should be kept a little above the usual standard 
of healthy comfort, and the air constantly impregnated with aqueous 
vapor. Some place much reliance on the inhalation of the vapor of hot 
water, in which quicklime is undergoing the process of slacking. I have 
seen it perseveringly tried many times, but with very little effect. I 
regard it of far less importance than the lactic acid spray, and even less 
beneficial than the old-fashioned remedy, consisting of the free inhalation 
of the vapor from a hot infusion of hops in vinegar. 



SEQUELS. 177 

Convalescence, — Due attention should be given to the management of the 
period of convalescence from all grades of diphtheria. To secure a proper 
action of the skin and kidneys, and promote the renewal of a healthy tone 
and sensibility in the muscular and nervous structures, the patient should be 
kept much at rest; well protected from sudden atmospheric changes by 
flannel underclothes; judiciously supplied with fresh, dry air, and plain, 
nutritious, and easily-digestible food. In the convalescence from severe 
eases, the taking of a small dose of strychnine or dux vomica, with a solu- 
ble salt of iron at each regular meal-time, will be of much benefit, both in 
hastening the return of strength and in lessening the risk of paralysis. 

Prophylaxis, — The best means of preventing the spread of diphtheria 
is to isolate, as far as practicable, all cases as they occur, and maintain 
essentially the same sanitary regulations as I mentioned for the preven- 
tion of typhus and typhoid fevers. 

Sequelce. — Congestion of the cortical texture of the kidneys, and gen- 
eral dropsy occasionally occur as a sequel of diphtheria, though much less 
frequently than after scarlet fever. For the treatment of such cases I 
refer you directly to the lecture on the sequelse of the fever just named. 
The most frequent and troublesome of the affections that are liable to 
arise during the convalescence from diphtheria is some form of paralysis. 
In most cases it is limited to the muscles of the fauces and pharynx, and 
is only sufficient to simply give the voice a decided nasal quality, and 
make deglutition a little difficult; but is sometimes so complete as to 
render swallowing altogether impossible. During the prevalence of the 
disease in this city in 1858-9, I saw a case of this kind with the late Dr. 
J. A. Collins. The patient was a boy about eight years of age; and it was 
necessary to feed him liquid nourishment through a stomach-tube for two 
weeks, before he regained the power to swallow anything. 

While the paralysis more frequently attacks the muscles of the fauces 
and throat, it may manifest itself in any one or more of the voluntary 
muscles in any part of the body and extremities. Or it may attack one 
set of muscles after another, until, like rheumatism, it has passed in suc- 
cession over a large proportion of the voluntary muscles of the system. 
A case of this kind was brought to the Mercy Hospital two years since. 
It was in the person of a young man who had passed through a moderately 
severe attack of diphtheria, and recovered so far that he had begun light 
out-door work. 

He first lost the power of speech and deglutition. In a few days these 
functions began to improve, when he lost all voluntary motion of the mus- 
cles of one side of his face and eye. Just as he was regaining control 
over these, the paralysis involved the muscles of both upper and lower 
extremities, and was so near complete that he could neither feed himself 
nor stand on his feet. It was at this stage of his disease that he was 
brought into the hospital. The paralysis following diphtheria, whether 
partial or complete, appears to be a simple loss of nervous force or mus- 
cular contractility, and is not accompanied by any inflammatory or febrile 
symptoms, or even local pain and soreness. It very generally tends 
towards recovery, and probably never ends fatally, except in very rare 
instances, when it attacks the muscles of respiration or of the heart. No 
case has terminated fatally or failed to recover, within the circle of my 
own practice. The only remedies necessary are rest, good air, nutritious 
and easily-digestible food, and muscular and nerve tonics. 

Of the latter, we have none better adapted to these cases or more 
promptly curative than strychnine, citrate of iron, and the hypophosphites. 
To an adult or patient over fifteen years of age, I give a pill or capsule 
12 



178 PERIODICAL FEVERS. 

containing strychnine, two milligrams (gr. 1-30), and citrate of iron, thir- 
teen centigrams (gr. ii), before each meal-time; and four cubic centi- 
meters (fl. 3i) of either the syrup of the lacto-phosphate of calcium or of 
the compound syrup of the hypophosphite of sodium, calcium, and iron, 
half an hour after each meal. Of course, proportionately less doses must 
be given to younger children. 

Under such management the patients usually make a good recovery in 
from one to four weeks. The daily application of mild currents of elec- 
tricity or galvanism has also proved beneficial. 



LECTUKE XX. 

Periodical Fevers— Their History, Causes, Varieties, and General Pathology. 

GENTLEMEN: — I now invite your attention to the second group or 
family of acute general diseases, usually styled periodical fevers. The 
individual fevers included in this group are fewer in number and much 
more closely allied to each other than those constituting the first division, 
under the general name of continued fevers. They are really varieties or 
different grades of one acute general disease, arising from the same efficient 
cause, prevailing at the same times and places, and readily convertible from 
one into the other. 

History. — The periodical fevers have been known and described, from 
the earliest records of medicine, under the names of paludal fever, marsh 
fever, endemic fever, ague, bilious remittent, and periodic fever. They 
have often, also, been named from the locality or country where they pre- 
vail, as the African, Bengal, Mediterranean, Walcheren, Chagres, Pan- 
ama fever, etc. At the present time they are very generally designate 1 
as periodical or malarial fevers. Their prevalence appears to be limited 
by certain meteorological and topographical conditions, independent of 
the social or sanitary condition of the people. For instance, a certain 
degree and duration of summer heat, acting upon a soil containing a suf- 
ficient amount of moisture and decomposable vegetable matter, appear to 
be conditions necessary to the development and spread of these fevers. 
If you go so far north or south of the equator, or ascend a mountain range 
so high, that you do not get a mean summer temperature equal to 16.9° C. 
(60° F.) for two consecutive months, you will find no prevalence of peri- 
odical fevers. If there are any exceptions to this rule, they are few and 
unimportant. On the other hand, if you have the longest and most intense 
summer heat, without the presence of both moisture and decomposable 
vegetable matter in the surface and sub-soils, you will find no prevalence 
of this variety of disease. Consequently, its chief prevalence is within the 
temperate and tropical zones, and on moist, alluvial, or tertiary forma- 
tions, at moderate elevations above the level of the sea. In Europe the 
regions most subject to the prevalence of periodic fevers are the whole 
western coast of Italy, including Tuscany, the Pontine Marshes, the Cam- 
pagna of Rome, and the environs of Naples; on the low lands along the 
southwestern coast of Spain and Portugal; the southern coast of France; 



HISTORY. 179 

the greater part of European Turkey, including Bulgaria, Albania, etc.; 
that part of Russia bordering on the Baltic and Black Seas, and in the 
valleys of the Danube, Dnieper, Don, and Volga rivers; the plains of 
Hungary, Croatia, and Slavonia; that part of Lower Austria along the 
Danube; the Baltic coast of Prussia; the western coast of Holland, includ- 
ing the marshy plains on the Rhine and its tributaries; and that part of 
Sweden bordering on the Baltic and along the river Angermann, as far 
north as G'-2° W N. latitude. The latter is said to be the most northern 
point of its prevalence in Europe. Iceland, Norway, the greater part of 
Denmark, the British Islands, Switzerland, and all mountainous districts 
of Central Europe are quite exempt from the prevalence of these fevers. 
In Asia, the great alluvial valleys of the Indus and the Ganges, the whole 
south and southwestern coast of China, the coasts of Syria and Asia Minor, 
on the shores of the Red Sea and Persian Gulf in Arabia, on the islands 
of Ceylon and Sumatra, and in Farther India, periodical fevers are very 
prevalent and severe. The same is true in reference to all the western 
and northern coast of Africa bordering on the Atlantic and Mediterranean, 
the valley of the Nile in Lower Egypt, and along the banks of the Gambia, 
Niger, and Senegal Rivers. In America, this variety of fever is endemic, 
and often severe in many of the islands of the West Indies, and on the low, 
alluvial lands bordering all sides of the Gulf of Mexico, which includes the 
northern coast of South America, the eastern coast of the Isthmus, Central 
America, and Mexico, and the southern coast of the United States, from 
the mouth of the Rio Grande to Key West. In addition to that part of the 
Southern States bordering on the Gulf of Mexico, this country presents 
four principal malarious districts: First, all the low, alluvial lands border- 
ing on the Atlantic from Florida to Rhode Island, in width extending from 
the foot of the Alleghany Mountains to the seashore. Second, the country 
bordering on the great interior lakes on our northern border, which 
includes the northwestern part of New York, the northern border of Ohio, 
Indiana, Illinois, and the whole peninsula of Michigan. Third, the great 
interior valley lying between the western foot of the Alleghany Mountains, 
on the east, and the eastern slope of the Rocky Mountains, on the west, 
and extending from Lake Superior and the elevated plateau west of that 
lake, on the north, to the Gulf of Mexico, on the south. The plateau of 
which I speak, lying west of Lake Superior and Lake of the Woods, is 
only from 1,500 to 1,800 feet above the level of the ocean; but it consti- 
tutes the great hydrographical axis of the continent, separating the waters 
that flow eastward through the Great Lakes and the St. Lawrence to the 
Atlantic, from thosejlowing north to the Arctic Ocean, and those flowing 
south through the Mississippi to the Gulf of Mexico; and constitutes the 
northern limit of the prevalence of the malarial fevers. The fourth district 
embraces the Pacific slope, extending from the foot of the Sierra Nevada 
Mountains to the coast, and extending from Mexico, on the south, to 
Alaska, on the north. Besides the extensive districts I have mentioned, 
there are many smaller valleys along rivers or on the borders of lakes, in 
almost every State where periodical fevers abound, more or less. The 
parts of our country most nearly exempt are the hilly and mountainous 
region extending from the northern part of Georgia and Alabama to the 
northeast, until it reaches the southwestern part of Maine, embracing the 
Cumberland, Alleghany, Catskill, and Adirondack ranges of mountains, 
and the White and Green Mountains of New Hampshire and Vermont; 
and the great mountain ranges intervening between the western border of 
the Mississippi valley and the Pacific slope, extending parallel with the 
Pacific coast from Mexico to the Arctic regions. 



180 PERIODICAL FEVERS. 

This latter immense mountain district, where it is crossed by the Union 
Pacific Railroad, is made up of lour nearly parallel ranges, called the 
Rocky Mountains proper, the Wahsatch, the Hum bolt, and the Sierra Ne- 
vadas, between which are the great elevated basins called the Green River, 
the Salt Lake, and the Humbolt Valleys. 

Causes of Periodical Fevers. — The fact that this variety of fevers is 
limited in its prevalence by certain geographical and topographical 
boundaries, shows that its essential cause arises from some conditions 
pertaining to the soil itself. As I have already stated, these conditions 
relate to the temperature, moisture, and decomposable vegetable matter. 
Where these exist in proper proportions, something is brought into ex- 
istence, or excited to activity, which is capable of exerting such influence 
upon the human system as to cause the development of those pathological 
changes and symptoms which constitute periodic or malarial fevers. As 
it requires not merely an elevation of temperature, but the maintenance of 
such elevation for at least two months, it brings the time for beginning 
the active development of the specific agent or influence past the climax 
of summer-heat, and continues it until the temperature falls too low in the 
autumn. Hence, the chief prevalence of these fevers in this city, as well 
as in all the middle and northern parts of this country, is during August, 
September, and October. In some seasons they begin to prevail earlier, 
and in others continue quite prevalent through the month of November. 
In those locations where the circumstances are highly favorable for gen- 
erating the specific cause, it is quite common to have a moderate prevalence 
of the intermittent form of the disease during the first continuous warm 
weather of spring. Irregular and relapsing cases are met with occasion- 
ally at all seasons of the year. 

That the local conditions I have enumerated as favorable for the preva- 
lence of these fevers, give rise to the development of a specific materies 
morbi, which constitutes their efficient cause, is clearly indicated by the 
following facts: First, persons previously healthy are often attacked with 
some form of the fever, as the result of spending only one or two days, at 
the proper season, in localities where the favorable conditions are highly 
concentrated, as on some parts of the coast of Africa, the campngna of 
Rome, or the swamps of Louisiana. Second, persons living in districts 
where the fevers are actively prevailing, are found to greatly lessen their 
liability to an attack by refraining from going out after the atmospheric 
vapor begins to condense in the form of dew in the evening, and until 
after it has again been dissipated and risen above the lower strata of the 
atmosphere in the morning. Third, families living on hillsides, so situated 
that the fog or vapor arising from a neighboring marsh or moist alluvial 
plain, is waited by the atmospheric currents or prevailing winds against 
them, have often been found to suffer more than their neighbors lower 
down the hillside and nearer to the marsh. So, also, families and whole 
settlements which had been for many years entirely exempt from this va- 
riety of sickness, have become sorely afflicted every season, after the 
cutting away of a grove or strip of forest trees, which had intervened 
between them and a more or less extensive marsh. Fourth, repeated 
instances have occurred in which the drinking of water from springs, rills, 
and wells supplied or percolating from a neighboring marsh or rich alluvial 
soil, has caused attacks of the disease. On the other hand, locations pre- 
viously highly infested with the disease, have been rendered quite exempt 
by thorough drainage and cultivation. So true is this, that large portions 
of our country, in which malarious fevers prevailed severely during the 
first two generations after their settlement, have now become nearly 
exempt from such prevalence. 



CAUSES. 181 

These and kindred faets not only prove that a specific material substance 
of some kind is produced, but that it is capable of being; held suspended 
in water and in aqueous vapor, and that its diffusion in the atmosphere is 
governed by the same laws as govern the diffusion of the latter. From a 
very early period this substance, or mater ies morbi, has been called ma- 
laria, marsh-miasm, koino-miasm, etc., under the belief that it was a 
subtle gas evolved by the action of heat on moist, decomposing vegetable 
matter in the soil. Until a recent period this theory was generally 
accepted by the profession, although the supposed gas successfully eluded 
every effort of the chemist to isolate and identify it. Suggestions were 
made from time to time, that the special agent is an organic germ, either 
animal or vegetable. One of the earliest and ablest advocates of the 
theory that malaria is a species of fungus or vegetable germ, was Dr. J. K. 
Mitchell, for many years one of the faculty of Jefferson Medical College, 
who gave the results of his observations and experiments in an interesting 
little volume, published in 1849. In 1866, Dr. J. H. Salisbury, of Cleve- 
land, published the results of his investigations, claiming that the active 
agent is a vegetable organism of the algoid class, called palmella. Several 
years since, Dr. John Bartlett, of this city, reported to the Chicago Medi- 
cal Society the results of an interesting series of investigations, somewhat 
confirmatory of the conclusions of Dr. Salisbury. And within the last two 
years, Drs. Klebs and Tommasi Crudeli have published the results of a 
still more extended series of observations near Rome, in which they claim 
to have proved that the essential cause of periodical fever is a low form of 
vegetable organism which they call bacillus malaria?,. They made a 
watery extract from the marshy soil of a malarious region, containing 
these germs, and by injecting it into rabbits, produced symptoms which 
they regarded as diagnostic of malarial fever. These gentlemen certainly 
succeeded in killing the rabbits, but the symptoms preceding their death 
were by no means identical with those of any variety of malarious fever. 
Moreover, the known readiness with which rabbits and guinea pigs are 
affected by the injection of almost any organic material into their blood or 
tissues, renders them wholly unfit for use in such investigations. During 
the past year, Dr. Gr. M. Sternberg, of the U. S. A., at the request of the 
National Board of Health, has been still further pursuing the same line 
of investigation as the Italian physicians, with additional observations 
concerning both the specific characters of the so-called bacillus malarice, 
and the range of temperature that rabbits may undergo when under no 
unnatural influence. From the facts given in his report recently pub- 
lished,* I am satisfied that the evidence thus far developed is wholly 
insufficient to justify the conclusions arrived at by Klebs and Tommasi 
Crudeli. On the contrary, the disease they produced in their rabbits 
differs in no essential symptoms or post mortem appearances from that 
produced in the same species of animal by the injection of healthy human 
saliva or any other organic material capable of undergoing septic changes; 
and their bacillus malariae differs in no recognizable specific characters 
from bacilli found in almost any foul water, under the influence of a 
summer temperature. The real nature and origin of the specific cause of 
periodic fevers is, therefore, still a mystery. The circumstances or condi- 
tions necessary for its production, and the laws governing its diffusion, 
have been well ascertained, as I have already stated to you ; and we may 
properly call it malaria, without intending thereby to imply anything 

* See Experimental Investigations by George M Sternberg, Surgeon U. S. A., relating to the Eti- 
ology of Malarial Fevers. National Board of Health Bulletin, Appendix No. 2. 



182 PERIODICAL I'EVEKS. 

concerning its nature, until further investigations shall result in its more 
perfect identification. Age and sex appear to exert little or no influence 
over the liability to attacks of malarial fever. 

Varieties. — All the varieties of periodical or malarious fever may be 
conveniently grouped under three heads, viz.: Intermittent, Remittent, 
and Pernicious. The first includes all those cases characterizjd by par- 
oxysms of fever of brief duration, with an interval of time between them, 
during which all febrile symptoms are absent. The second includes all 
such cases as are characterized by active paroxysms of fever, with a regu- 
lar interval between them, during which the febrile symptoms are greatly 
diminished but not entirely absent. Instead of a complete intermission, 
as in the first variety, there is only a remission. The third includes all 
such cases as are characterized by a dangerous degree of depression during 
the first stage of the paroxysm. 

In all the varieties the paroxysms recur at stated periods of time, with 
a near approach to regularity. In some cases they return at a given time 
every day ; in others every second, third, fourth, fifth, sixth, or seventh 
day ; and are technically called respectively, quotidians, tertians, quartans, 
quintans, sextans, and septans. Cases are also known in which the parox- 
ysms return every fourteenth day. Very much the larger number of cases 
of the intermittent variety present a febrile paroxysm every day or every 
second day. The next most numerous cases have a paroxysm every 
seventh or fourteenth day. In the remittent variety the paroxysms 
very generally recur every day. In the pernicious cases, if the patient 
does not die in the first paroxysm, they may take either the intermittent or 
remittent type, but much the larger number present the characteristics of 
the former. Most waiters mention cases in which two paroxysms occur in 
one day, and call them double quotidians, double tertians, etc. According 
to my experience, such cases are exceedingly rare. I have already made 
frequent mention of the words paroxysm, interval, intermission, and 
remission. A paroxysm of malarial fever consists of three stages, each 
presenting a distinct group of symptoms, and following each other in a 
pretty uniform order ; namely, the algid or cold stage, the hot or pyretic 
stage, and the declining or sweating stage. The interval is the length of 
time from the commencement of one paroxysm to the beginning of the 
next. The intermission is the length of time from the end of one parox- 
ysm to the beginning of the next. The remission is the period of time 
from the decline of one paroxysm to the accession of the next, and applies 
only to the remittent variety of fever. 

General Pathology. — A study of the general pathology of periodical 
fevers necessarily involves a consideration of the modus operandi of their 
specific cause, called malaria. This agent evidently gains access to the 
human system chiefly through the lungs, by inhalation w T ith the air and 
aqueous vapor, and to some extent also, through the stomach with water 
and other liquids, capable of holding it in solution. When received into 
the blood through either channel in sufficient quantity to produce general 
disturbance, it acts upon the properties of the tissues as an irritant, increas- 
ing the general susceptibility, and at the same time impairing the force of 
vital affinity, while it exerts a special local influence over the functions of 
the vasomotor nervous system. The irritant effect gives to the febrile 
movement the same rapidity of development and active excitement that 
belongs to the febricuke, while the impaired tonicity of the tissues favors 
congestions or the undue accumulation of blood in the more vascular 
structures, such as the spleen, lungs, liver, and mucous membranes; and 
and at the same time the special action on that part of the vasomotor 



GENERAL PATHOLOGY 1#3 

nerves controlling the peripheral circulation is such that the vessels of the 
surface become much contracted, causing it to appear pale, shrunken, and 
cold. But the rapid accumulation of heat in the internal hyperaemic 
structures soon increases the temperature of the blood to such a degree 
that it overcomes the contraction of the peripheral vessels, and not only 
carries the increase of heat throughout the whole system, but ultimately 
cooperating with the impairment of vital affinity, causes that relaxation 
which constitutes the sweating stage, and ends, for the time being, the 
febrile excitement. If the relaxation is complete, allowing a free exuda- 
tion or sweating from the cutaneous surface, the exciting cause appears so 
far removed that all active phenomena cease, constituting the intermission. 
If the relaxation be only partial or imperfect, allowing only a lowering of 
temperature with slight moisture of the surface, it constitutes only a remis- 
sion between the paroxysms. The first represents the intermittent, and 
the second the remittent variety of periodical fever. But when, from the 
intensity of the action of the malaria or some peculiarity in the condition 
of the patient, the vital affinity becomes so impaired as to greatly retard 
all molecular changes, and not only the vasomotor function of the per- 
iphery, but of the whole system, is perverted, the active generation of heat 
fails internally as well as externally, allowing the cold stage to continue, 
with shrinking, blueness, and coldness of the surface; a rapidly failing 
pulse; unsteady respiration; entire suspension of innervation and secretion, 
and death within a few hours. 

Such cases constitute the true algid variety of pernicious intermittens. 
When the extreme impairment of the vital affinity is coupled with such an 
alteration of the vasomotor influence as causes paralysis or relaxation of 
the vessels of the mucous membrane of the alimentary canal, as well as of 
the cutaneous surface, giving rise to copious, thin or serous discharges by 
vomiting and purging — which often ends in complete collapse and death 
during the first paroxysm — it constitutes the choleraic variety of the per- 
nicious cases. Sometimes, on the accession of a paroxysm, the extreme 
failure of vasomotor influence is limited mostly to the pulmonary vessels, 
including an engorgement of the vascular capillary network, so complete 
as to cause rapid exudation and compression or filling up of the air-cells, 
and consequent speedy death of the patient by suffocation. 

A similar but less intense impairment of the vital affinity and vasomotor 
nerve influence, limited mostly to the brain or cerebro-spinal nerve cen- 
ters, causes the pernicious cases styled in your text-books Soporose or 
cerebro-spinal intermittents. Such are the morbid processes which con- 
stitute the essential pathology of the different varieties of malarial fever. 
If the patient lives through the first and second paroxysms, as in the 
ordinary variety of intermittent and remittent cases, and the disease con- 
tinues its natural course, other important pathological changes take place, 
with greater or less rapidity, during the further progress of each case. 
The active disturbance of those elementary properties of the tissues on 
which the molecular changes constituting nutrition, disintegration, and 
secretion depend, with the renewed hyperemia of the digestive and assim- 
ilative organs at each returning paroxysm, arrests or greatly retards the 
formation of new organizable constituents of the blood, especially the red 
corpuscles and albumen; and at the same time the disintegration and waste 
of those already existing are increased, both by the heat and excitement 
of the paroxysms, and sweating or other evacuations at their close. Con- 
sequently, the blood becomes rapidly impoverished of its red corpuscles, 
albumen, and some of its salts, while the fibrin, white corpuscles, and 
extractive matter remain in nearly natural proportion. In addition to 



184 PERIODICAL FEVERS. 

these changes, the microscope shows the existence, in the serum of the 
blood, of many small black specks or granules, apparently derived from 
the has matin of the disintegrated red corpuscles. 

This same pigment or coloring matter is found staining the walls of the 
blood-vessels quite generally, giving rise to a somewhat characteristic 
change of color in the liver and spleen, and doubtless contributing to the 
formation of that sallow hue of the surface generally presented by persons 
subject to protracted ague. The extreme degree to which the blood is 
deprived of its red corpuscles in some cases of protracted intermittent*, 
was shown by some of the analyses made by myself in 1S52.* 

In one instance, the blood taken from a vein in the arm of a laboring 
man who had had a paroxysm of simple intermittent fever every day for 
about ten weeks, yielded, on very careful analysis, only 49.19 per 1,000, or 
a little less than five per cent, of red corpuscles ; 64.84, or less than 6.5 
per cent, of albumen, and 1.38 or 0.13 per cent, of fibrin. In another case, 
also analyzed in November, 1852, the blood taken from the arm of a labor- 
ing man aged 23 years, who had suffered from quotidian ague six weeks, 
gave 82.79 per 1,000, or 8.2 per cent, of red corpuscles ; 69.68, or near 7 
per cent, of albumen ; and 2.48, or near 0.25 per cent, of fibrin. Both the 
specimens of blood I have alluded to were also subjected to a careful ex- 
amination with the microscope. The red corpuscles appeared to me slightly 
distended or more globular than natural, and some of them had a corru- 
gated or shrivelled appearance, as if undergoing disintegration. The white 
corpuscles were less numerous than in healthy blood. There were also 
many minute dark granules floating in the serum. Between the years 1856 
and 1859, Dr. Joseph Jones, then Professor of Medical Chemistry in the 
Medical College of Georgia, at Augusta, made a large number of analyses 
of blood from patients laboring under different grades of malarial fever, 
the results of which he gave in a lengthy and important paper presented 
to the American Medical Association in May, 1859. So far as relates to 
the alteration of the relative proportion of the constituents of the blood, his 
analyses led to the same results as my own.j- 

In addition to his chemical analyses, Dr. Jones embraced opportunities 
more frequently presented in the intensely malarious district in which he 
then lived, for making minute jjost mortem examinations of many fatal 
cases of remittent and pernicious intermittent fevers, and found the serum, 
or liquor sanguinis, of a decided yellow color ; unusually extensive and 
numerous fibrinous clots in the cavities of the heart and larger blood- 
vessels, of such firmness and freedom from colored corpuscles as to indicate 
their formation before death ; and in most cases enlargements and altera- 
tions in the color of the liver and spleen. He states that the blood in the 
liver and spleen does not change to a brighter hue on exposure to the 
oxygen of the air, as in other parts of the body, and that in the many 
cases examined for that purpose, he uniformly found the liver containing 
an increase of animal starch or glucogene, but no grape sugar. 

In nearly all the cases of death from the remittent type of fever, the 

*See Report on the Changes which take place in the Blood in the Continued and Periodical 
Fevers, read to the Illinois State Medical Society in June. 1857. By N. S. Davis, M. D., etc. Pub- 
lished in the Transactions of the Society for 1857, and a'so m thvj [Northwestern Med. and Surg. 
Journal, Vol. VI, New Series, pp. 389-398. 

f The following are the conclusions of Dr. Jones, in his OAvn words : 1. The careful comparison 
of the table of the changes of the blood in malarial fever, with the formula of the blood, established 
by laborious investigations, reveals the fact that the colored blood-corpusc e< ore diminished during mala- 
rial fever. 2. The careful comparison of these analyses with each other, reveals the faci that the 
ex ent a'id rapidity of the diminution of the colored cor uscles corresponds to the severity and extent of 
the disease. 3. Our researches show that the fixed saline constituents of the blood-corpuscles are 
often diminished in malarial fever. See Transactions of the American Medical Association, Vol. 
XII, pp. 379 and 385. 1859. 



PATHOLOGY. 185 

mucous membrane of the stomach and duodenum was found congested 
with blood ; and in some instances the same changes were found in the 
ilium, accompanied by tumefaction of the glands of Peyer. Without 
occupying your time with further details, I will close this part of the sub- 
ject by submitting the following brief propositions : — 

1st. The essential cause of periodical fevers gaining access to the blood, 
chiefly through the lungs and stomach, by its presence, exerts an excitant 
or irritative influence on the susceptibility of all the organized tissues of 
the body, while it so modifies the vital affinity as to impair their tonicity 
and lessen the natural molecular changes constituting assimilation, nutri- 
tion, and secretion ; and at the same time so modifies the action of the 
vasomotor nerves as to induce contraction of the peripheral or cutaneous 
vessels, while those of the viscera and internal structures remain un- 
affected or dilate from the general impairment of tonicity. 

2nd. When the cause acts feebly, but persistently, through considerable 
periods of time, the pathological conditions just stated will not be de- 
veloped in sufficient degree to present the active phenomena of fever, but 
will so retard hrematosis and nutrition as to cause spanasmia, or impover- 
ishment of blood corpuscles, imperfect secretions, and want of muscular 
and nervous force, — a condition often called malarial cachexias. 

3d. When the cause acts with sufficient intensity to actively develop the 
morbid impressions indicated in the first proposition, the coincident con- 
traction of the vessels of the periphery, and suspension of heat-production 
there, with the undue excitability and rapid accumulation of blood and 
heat in the more vascular and relaxed internal organs, speedily presents 
all the phenomena of the first or cold stage of the febrile paroxysm. But 
such a disparity in circulation and temperature between the external and 
internal parts of the body, must of necessity be of short duration. Either 
the irritative quality of the exciting cause will predominate, and the rap- 
idly increasing temperature and blood-pressure internally will increase the 
force and frequency of the action of the heart and larger blood-vessels, and 
soon cause the vessels of the periphery to relax and become hot and turgid 
with blood, constituting the second or hot stage of the paroxysm ; or, that 
quality of the exciting cause which impairs the play of vital affinity will 
so far predominate that when the first stage of the paroxysm is induced, 
there is not sufficient tone or molecular attraction in the cardiac and in- 
voluntary muscular structures to maintain efficient contractions. Conse- 
quently the circulation will grow more feeble, the respirations more 
irregular and inefficient ; natural secretory actions will cease; the capillary 
circulation will be retarded as much in the internal structures as in the 
cutaneous surface ; the blood, with its rapidly disintegrating red cor- 
puscles, will accumulate in the spleen, liver, and sometimes the lungs ; 
and in a few hours the patient dies in what is called a pernicious or 
congestive paroxysm. 

4th. When the irritative influence predominates and the hot stage of the 
paroxysm readily supervenes, the rapid increase of heat in the tissues, and 
the equally rapid increase of effete matter in the blood, both from retarded 
eliminations and morbid changes in the corpuscular elements of the blood 
itself, soon begin to neutralize the excessive excitability, and in a few 
hours the cutaneous vessels become entirely relaxed, permitting copious 
•sweating, with a coincident resumption of more natural secretions in the 
internal organs, and accompanied by an entire subsidence of fever or an in- 
termission. In other cases the cutaneous relaxation and sweating is only 
partial, accompanied by an equally imperfect subsidence of the fever or a 
remission. But in either case, if not interfered with by treatment, the 



186 PERIODICAL FEVERS. 

intermission or remission continues only for a definite limited time, when 
the susceptibility to the action of the special cause is regained, and the 
successive stages of another paroxysm supervene; and this regular succes- 
sion of morbid phenomena may continue without any definite self- 
limitation. 

5th. When the morbid phenomena just named are permitted to recur from 
day to day, the high excitement, coupled with vascular hyperemia of the 
abdominal viscera, that is renewed with the access of each paroxysm, tends 
strongly to establish either sub-acute inflammation in the spleen, liver, 
gastro-intestinal mucous membrane, and lungs, or a rapid enlargement of 
the two first-named organs, partly from excessive accumulation of the 
corpuscular elements of the blood, and partly from actual hypertrophy of 
their tissue. In the meantime, the blood itself is undergoing rapid impov- 
erishment of its red corpuscles, both from their more active destruction 
and the continued interference with the natural processes by which they 
are reproduced. 

Such, gentlemen, are my views of the modus operandi of malaria, as the 
efficient cause of periodical fevers; and of the pathological conditions and 
processes that characterize the several stages and varieties of this very 
important group of acute general diseases. A consideration of their clin- 
ical history and treatment must be reserved for another hour. 



LECTURE XXL 

Periodical Fevers Continued— Intermittent. Remittent— Their Symptoms, Diagnosis Tro^nosis 
anJ Treatment. ' 

GENTLEMEN: — The active febrile symptoms in almost all cases of 
malarial fever, are preceded by feelings of indisposition, consisting in 
dull pains in the head, back, and limbs, more especially during a certain 
part of each day ; variable appetite ; undue sensitiveness to atmospheric 
changes ; and more or less derangement of the secretory functions gener- 
ally. These prodromic symptoms may continue from two days to as many 
weeks. For both convenience and accuracy, I shall describe the symp- 
toms of each variety of the fever separately. 

Inter mittents. — The symptoms of intermittent fever are naturally 
divided into those belonging to the paroxysm and those of the intermis- 
sion. As I stated to you in the preceding lecture, the paroxysm is made 
up of three stages, and each of these is characterized by a distinct group 
of symptoms. The cold stage is ushered in by feelings of coldness and 
general depression ; shrinking and paleness of the skin, and a leaden hue 
of the lips and nails ; the coldness being first in streaks along the spine, 
soon deepens into general shivering and muscular trembling, with chatter- 
ing of the teeth ; a small and variable pulse ; short and irregular respira- 
tory movements ; often increased secretion of limpid urine, and dull pains 
in the head, back, and limbs. In many cases there is frequent sighing, and 
a very uncomfortable sense of oppression in the epigastrium, with a general 
feeling of weariness. While the patient thus feels depressed, as if from 



INTERMITTENT. 187 

intense cold, the application of the clinical thermometer shows the actual 
reduction of temperature to be limited to the surface of the body and ex- 
tremities, while it is two or three degrees above the natural standard in 
the mouth and rectum. The average duration of the cold stage is from 
thirty to forty-five minutes. In some cases it is no more than ten or 
fifteen minutes, and may be absent altogether. On the other hand, it has 
been observed to last two and three hours in some rare instances. The 
transition from the cold to the hot stage is generally gradual, though 
occupying not more than ten or fifteen minutes. The patient first be- 
comes more quiet, takes deeper and more regular inspirations, his shivering 
ceases, irregular streaks of warmth come and go along the spine, like the 
streaks of cold at the beginning of the cold stage ; then warmth appears 
in the cheeks, the leaden hue disappears from the lips and nails, and soon 
the whole surface becomes warm, the skin smooth, the face flushed, trie 
pulse and respirations full and uniform, but more frequent than natural. 
In the meantime, the patient has been gradually throwing off his extra 
coverings and calling for the removal of the hot things that had been 
applied to his surface and extremities, until he complains of the excess of 
heat as much as he did of the cold a short time previous. 

The hot stage thus fairly established, is characterized by general heat 
and dryness of the surface; flushed face and rather excited expression of 
countenance; pulse full, and from 90 to 100 in frequency; respirations 
moderately accelerated; the lips red and dry; tongue generally coated 
with a thin, rather yellowish-white fur; the urinary secretion now scanty 
and high-colored; and the patient complains of much heat, thirst, restless- 
ness, throbbing pains in the head, with some general soreness of the flesh 
and sensitiveness to light and noise; some tenderness and distress in the 
epigastrium, and, not unfrequently, active vomiting, especially after taking 
drinks freely. The temperature continues to rise after the accession of the 
hot stage, and generally reaches its climax for that paroxysm in about one 
hour after the disappearance of cold from the surface and extremities, 
when it ranges between 40° and 41° C. (104° and 106° F.) in the axilla. 

AH the symptoms mentioned usually continue with but little change 
from two to four hours, when the patient begins to rest more quiet, and 
complains less of headache and thirst. Soon a slight moisture appears on 
the forehead, in the axilla, and in the palms of the hands, and in half an 
hour more the whole surface is covered with a copious sweat, which may 
continue from two to four hours, during which time the patient usually 
sleeps quietly. The sweat is generally copious enough to wet thoroughly 
all the clothing in contact with the patient. 

The sweat contains an unusual amount of organic matter, fat acids, and 
salts ; and gives a strongly acid reaction ; and during its progress all the 
active symptoms of the hot stage disappear, leaving the pulse, respiration, 
and temperature natural, and the patient comfortable, except a sense of 
weakness and weariness on attempting any exercise, and sometimes a light 
coating on the tongue and indifference to food. 

The urea, urates and chlorides, which had been largely in excess in 
the urine during the hot stage, rapidly decline during the sweating, and 
fall below the natural proportion in the intermission. From the descrip- 
tion I have given, you will perceive that the three stages united make the 
entire length of a paroxysm from five to nine hours, leaving from fifteen to 
nineteen hours for the intermission in the quotidian, and from thirty-nine 
to fourty-three hours in the tertian variety. At the end of the intermis- 
sion the cold stage again commences, and is followed by the same succes- 
sion of stages, and characterized by the same symptoms as in the first 



188 PERIODICAL FEVERS. 

paroxysm. The recurrence of paroxysms and intermissions may thus con- 
tinue with a near approach to regularity, both in time and symptoms, if 
not interfered with by treatment, for an indefinite period of time, during 
which the blood is steadily becoming" more and more impoverished of its 
red corpuscles and nutritive constituents, the epigastrium more con- 
stantly tender to pressure, and the liver and spleen, from the repeated 
congestions, considerably enlarged ; and the skin of a sallow color, from 
the combined effect of altered blood corpuscles and retained coloring matter 
of bile. When the disease thus continues for several weeks, it is called 
chronic ague, and is sometimes accompanied by such a degree of impover- 
ishment of the blood and impairment of the tone of the tissues as to in- 
duce general dropsical infiltration, or oedema of the areolar tissues. In 
some cases of intermittent fever each succeeding paroxysm commences a 
little earlier than the preceding one, and its hot stage continues longer, 
thereby shortening the intermission. Such cases, if not interfered with, 
are liable to become converted into the remittent form during the second 
week of their progress. On the other hand, there are cases in which 
each succeeding paroxysm begins from one to two hours later than the 
one preceding. 

These often terminate spontaneously in convalesence during the sec- 
ond or third week of their progress. Besides these variations in the pro- 
gress and termination of different cases of intermittent fever, you will 
meet with occasional variations in the order and phenomena of the sev- 
eral stages of the paroxysm itself. In some, the cold stage will be want- 
ing, or so slight as to be hardly noticeable. In others, the hot stage will 
be disproportionately long, and the sweating stage less profuse. These 
constitute what Dr. D. Drake called inflammatory intermittents. The 
paroxysm may commence in any part of the day; but in far the larger 
number of cases it beo-ins between six and eleven o'clock a. m. In the 
intermissions between the paroxysms, the patient often feels no other 
consciousness of being ill, than a sense of debility, or getting easily tired 
on exercise of body or mind. In some cases, however, the tongue remains 
coated and the secretions unnatural, with a sense of fullness in the epi- 
gas.ric and hypochondriac regions, from congestion or enlargement of the 
liver and spleen. In highly malarial districts, cases are met with in which 
there are no open paroxysms of fever, and yet the patients grow pale, 
lose their appetite, and experience a sense of heaviness, and dull pains in 
the head, back, or limbs during a part of each day. Although these cases 
present no marked chills or heat of surface, yet the thermometer in the 
mouth or under the tongue shows a rise of two or three degrees of tem- 
perature each day. These are called latent intermittents. 

\Yhen a similar condition of the system, depending on malarial influence, 
exists coincidently with other diseases of an inflammatory character, the 
intermittent is said to be masked. Cases also frequently occur, in which 
a severe paroxysm of neuralgia recurs at a stated period each day or every 
second day, and appears to take the place of the febrile exacerbation. 

Remittent Ftver. — The remittent variety of malarial fever prevails in 
the same localities, at the same seasons of the year, and under the same 
circumstances as the intermittent variety. Its prodromic or forming 
stage is the same ; and its first paroxysm is ushered in by the same well 
marked cold stage or chill, followed by a hot stage, presenting every 
characteristic symptom of the hot stage of an intermittent, except that it 
continues much longer, being usually from twelve to eighteen hours ; and 
instead of terminat.ng in a full, copious sweat, with entire disappearance 
of febrile phenomena, it subsides only so far that the skin becomes moist, 



REMITTENT. 189 

the pains cease, and the patient sleeps, but the pulse continues from ten 
to fifteen beats per mi mite faster than natural, and the temperature from 
one to three degrees higher. 

Hence it is called a remission or diminution of the fever, instead of an 
intermission. About the same hour that the initial chill occurred, which 
is, in most cases, between seven and eleven o'clock a. m., the febrile par- 
ox vsm recommences, and continues through the same length of time, and 
presents the same active symptoms as the first, except that the cold stage 
is less marked; and after the first two days amounts only to a brief period 
of coldness of the extremities, a little blueness of the lips and nails, pale- 
ness of countenance, and a desire for more clothing or covering on the 
bed. The paroxysms thus commenced, in remittent cases usually recur 
every day; and as the hot stage, or period of high irritative excitement, is 
protracted, and the subsidence only partial, the patient becomes more 
rapidly exhausted; the tenderness and sense of oppression in the epi- 
gastric and hypochondriac regions, more severe and constant ; the urinary 
secretions more scanty and high colored ; the tongue more thickly coated 
and mouth more dry ; the mind more likely to be wandering or delirious 
during the height -of each paroxysm ; and he 'ore the end of the first week 
the skin is apt to become more or less yellow, with physical signs of en- 
largement of the liver and spleen. When this variety of fever is not 
materially modified by treatment, the cases are found to progress in three 
directions. In the more severe attacks, especially in the warmer climates, 
the initial chill is severe, and the hot stage characterized by intense 
throbbing pain in the head, with more or less delirium ; great epigastric 
distress, with frequent vomiting of yellow or green fluid; very scanty 
urine ; severe engorgement of the liver and spleen, indicated by enlarge- 
ment of those organs; a rapid pulse, and temperature of 41° to 43° C. (106° 
to 110° F.); and a remission characterized by much weakness and little or 
no perspiration. Under the daily renewal of such paroxysms, the patient 
becomes rapidly prostrated ; the remissions less marked ; the pulse more 
rapid, but soft ; mind more continuously wandering ; mouth and tongue 
dry with sordes ; skin and eyes yellow ; epigastric and hypochondriac re- 
gions full ; sometimes spontaneous diarrhoea ; and somewhere between the 
fifth and ninth days entire suppression of urine, involuntary intestinal 
discharges, complete collapse, and death. Some of these cases are accom- 
panied by petechial or hemorrhagic spots on the surface, or by more copious 
discharges of blood from the stomach and bowels, or both. Late in the 
autumn, and in the spring, these severe cases are often accompanied by a 
dangerous degree of pneumonic engorgement of the lungs. 

Cases of the same class but a little less severe, often occur, in which the 
hot stage of the paroxysm becomes more and more prolonged, until the 
daily remission is nearly obliterated, and all the symptoms approximate 
closely to those of severe typhoid fever; and in the latter part of the sec- 
ond, or during the third week, they exhibit the dry, brown tongue, sub- 
sultus, mental wandering, and imperfect control over the sphincters, that 
indicates the near approach of a fatal result. Another, milder, class of 
cases are met with in which the hot stage of each returning paroxysm is 
shorter than the preceding one, and the remission more distinct. The 
tendency of such is to terminate, about the end of the first week, in a full 
sweating stage and complete intermission, to be followed by ordinary par- 
oxysms of intermittent fever, either of the quotidian or tertian form. A 
still milder class of cases run about the same course as the last mentioned, 
and terminate in a full intermission and permanent convalescence. 

Pathological Anatomy. — The pathological changes in the blood and 



190 PERIODICAL FEVERS. 

different organs of the body were so fully stated in the preceding lec- 
ture, when discussing the general pathology of malarial fevers, that only a 
few words need be added here. The post mortem appearances presented 
in fatal cases of intermittents and remittents are nearly the same. Leav- 
ing the pernicious or truly malignant cases for separate consideration, I 
may state that the chief changes observable on post mortem examinations 
are the diminution of the red corpuscles and appearance of black pigment 
granules in the blood; the appearance of the latter in many of the organs 
and tissues of the body, but more especially in the spleen, liver, and mar- 
row of the bones; the decided congestion and tumefaction of the spleen, 
liver and mucous membrane of the stomach and duodenum; and some- 
times a moderate degree of tumefaction of the solitary and aggregated 
glands of the ilium, the latter presenting what has been called the shaven 
beard appearance. 

When death has taken place early in the progress of the general 
disease, the liver and spleen present a dark bluish color, and their en- 
largement is caused chiefly by the accumulation of dark blood. When 
the course of the disease has been more protracted, these organs are more 
dense from some hypertrophy or hyperplasia of the connective tissue and 
increase of lymphoid cells, and the color of the spleen is lighter or nearer 
slate color, and that of the liver more of the olive yellow, varying from 
light olive to the bronzed hue. In the more protracted cases some degree 
of the fatty, waxy and amylaceous molecular degenerations can also be 
found in the parenchyma of many of the organs, but in much less degree 
than in the continued fevers, as the typhoid and typhus. 

Diagnosis. — The unmixed or uncomplicated cases of either intermittent or 
remittent fever are easily distinguished from all other general febrile affec- 
tions when they have progressed far enough to pass one or more paroxysms. 
The well marked initial chill, followed by a high irritative grade of fever, 
with its rapid rise of temperature, continuing from three to eighteen or 
twenty hours with an equally rapid decline, nearly or quite to the standard 
of health, the same to be repeated at intervals nearly regular as to time, 
every day or every second day, constitute an assemblage of symptoms so 
different from those of all the other fevers, that no other diagnostic marks 
are needed. It is only when the specific causes of yellow fever, or of 
typhoid or typhus are actively prevalent at the same time and in the same 
places with the malarial fevers, that you will meet with cases in which the 
symptoms of different types of fever become so blended in the same case, 
as to lead you into errors or uncertainties regarding the diagnosis of individ- 
ual cases. That such blending is not only possible, but of frequent occur- 
rence in all places naturally malarious, into which the causes of yellow and 
typhoid fevers are introduced, either by commerce or by accumulations of 
population, I have already abundantly shown in the lectures on those dis- 
eases. And at the same time I pointed out the most available means for 
maintaining the line of differential diagnosis in such cases, and will not 
repeat them here.* 

Those protracted cases of remittent fever, in which, during the third 
week, the fever becomes more continuous, with mental wandering, dry, 
brown tongue, some degree of subsultus, and perhaps diarrhoea, if pre- 
sented to you for the first time in that condition, with no one present to 
give a correct history of the case, might cause you to hesitate or feel un- 
certain in regard to the question as to whether it was malarial or true 
typhoid. But even in such cases, there is a more yellow shade of color in 

* See pp. 93-91 and 145 of this Vol. 



TREATMENT. 191 

the skin and eyes, greater paleness of the prolabia from impoverishment 
of the red corpuscles of the blood, and less abdominal tympanites, than in 
the corresponding- stage of typhoid fever. 

Prognosis. — Excluding the cases of a decidedly pernicious character, 
periodical fevers, whether intermittent or remittent in form, are not at- 
tended by a high ratio of mortality. And in such cases as do terminate 
fatally, death is generally caused by the supervention of local inflamma- 
tions in some of the important organs, and not from the gravity of the 
general disease. Yet, if either from neglect or inefficiency of treatment, 
the fever is allowed to run an unusually protracted course, the progressive 
impoverishment of the blood and impairment or perversion of molecular 
changes in the tissues, may cause fatal exhaustion. As a rule, the ratio of 
mortality is much greater in warm or tropical climates, than in the tem- 
perate or colder regions. It is much greater in some years than in others 
in the same locality. Neither age, sex, color or nationality, appear to 
have any influence over the liability to be attacked, or over the resulting 
mortality. One attack does not in any degree lessen the susceptibility to 
subsequent attacks, but rather the reverse. The disease is not in any 
degree contagious; neither is its cause portable or capable of being car- 
ried from place to place. 

Treatment. — There are three distinct objects to be accomplished in the 
treatment of all non-malignant cases of periodical or malarial fevers, 
namely: first, to palliate or lessen the more important symptoms during the 
paroxysms; second, to interrupt or prevent their recurrence; and, third, 
to aid in restoring the proper proportion of the constituents of the blood, 
and the natural condition of the properties of the tissues, and thereby 
more certainly prevent relapses. The several stages of a paroxysm of an 
ordinary intermittent fever are so brief, that very little treatment of a pos- 
itive character is needed. The patient should be placed in bed as soon 
as the cold stage is felt approaching, well covered, with the addition 
of bottles of hot water, hot bricks, or ot».ier means of dry warmth to the 
extremities; and if any medicine is administered internally, from two to 
three cubic centimeters of chloroform (min. xxx to xlv) given at once, well 
diluted with sugar and water, will be more likely to lessen the severity 
and duration of the cold stage than any other remedy. The common cus- 
tom of allowing the patient to drink freely of hot, pungent, or stimulating 
drinks during the cold stage, is worse than useless. By filling the stom- 
ach with such liquids, you are much more likely to provoke vomiting and 
increase the epigastric distress as the hot stage supervenes, than you are 
to lessen the severity of the chill. Dr. Mackintosh of Edinburgh recom- 
mended free bleeding at the beginning of the cold stage ; Dr. Wright, of 
Chatham, Illinois, recommended hypodermic injections of sulphate of mor- 
phia; and many others have given a full dose of opium, for the same 
purpose. White there is abundant evidence that either of these remedies, 
will in many cases, greatly lessen the severity of the cold stage, the danger 
of producing either direct or secondary bad effects, more than counterbal- 
ances all the benefit they can produce in ordinary cases of malarial 
fever. When the hot stage supervenes, and the skin becomes hot 
and dry, frequent sponging of the surface with cold water; the ap- 
plication of cold cloths to the bead; cooling drinks in small quan- 
tities but frequently repeated; and moderate doses of an efficient 
arterial sedative, will contribute most to mitigate the severity of the 
febrile excitement, lessen the tendency to kindle up inflammatory compli- 
cations, and add to the comfort of the patient. The best sedatives for 
this purpose are aconite and veratrum viride. From 0.06 to 0.12 cubic 



192 PERIODICAL FEVERS. 

centimeters (min. i to i'l) of the strong tincture of either may be given 
every hour until the hot stage begins to decline, when it should be sus- 
pended. This is all the treatment necessary so far as relates directly to 
the paroxysms of ordinary intermittents. But in remittents, in which the 
hot stage is more protracted, and the symptoms of gastric irritation and 
visceral congestions are more prominent, it is better to give the arterial 
sedative in larger doses, at intervals of once in two hours, and at the in- 
termediate hour give a powder composed of calomel 0.13 grams (gr. ii) 
and bicarbonate of sodium 0.33 grains (gr. y). These, like the sedative, 
should be discontinued on the decline of the paroxysm, and if the bowels 
fail to move during the next twelve or eighteen hours, a laxative should be 
given sufficient to effect that object. During the sweating stage, or de- 
cline of the paroxysm, no special treatment is required except rest and 
dry clothes when it is ended. To accomplish the second object I have 
named as important, namely, to prevent the recurrence of the paroxysms, 
requires the use of the class of remedies called anti-periodics. Of these 
the sulphate of quinia is, undoubtedly, the most reliable, in the great 
majority of cases. But the other alkaloids of the Peruvian bark, the ac- 
tive principles of the bark of the cornus florida, the salix alba, etc., pos- 
sess sufficient efficacy to be used with advantage in many cases; more 
especially in such patients as are affected unpleasantly by the quinine. 
It is probable that quinia and all the vegetable alkaloids possessing anti- 
periodic properties, produce their curative influence by directly antagoni- 
zing the effects of the malaria on the properties of the tissues and the 
function of the vaso-motor nerves. In the preceding lecture I stated that 
the essential or direct pathological conditions produced by malaria, were, 
an increase of the susceptibility of the living structures, a diminution or 
impairment of the vital affinity, and such an influence on the vaso-motor 
centres as to induce active contraction of the whole system of peripheral 
or cutaneous vessels. The sulphate of quinia, however, when used in fair 
doses, directly diminishes the susceptibility, while it increases the force of 
affinity in the tissues, and so impresses the vaso-motor centres as to favor 
relaxation, if not temporary paralysis, of the vessels of the surface. In 
small doses its influence on the vital-affinity and consequent tonicity of 
the tissues predominates, and hence when thus administered it has been 
regarded as a tonic. In large doses its effect in directly diminishing the 
susceptibility or excitability of the structures and modifying the vaso- 
motor function, caused it to be claimed, in former times, as a powerful 
sedative,* and more recently as an anti-pyretic. That it is capable of 
producing these effects, even to a degree destructive of life, is fully proved 
by experiments on animals, by accidental experiments on the human sub- 
ject, and by clinical observations at the bed-side, f It is only a few days 
since, that I saw a patient with typhoid fever, evidently complicated with 
malarial influence, in which the exhibition of moderately full doses of 
quinine for three or four days in succession, had induced great impair- 
ment of hearing and vision, and a dangerous degree of depression, with 
insomnia, and what the family called " sinking spells." 

Some practitioners have attributed to quinine important germicide prop- 
erties ; but I do not think its effects on the human system are, in any 
degree, dependent on its power to destroy bacteria or micrococci. The 
arsenical preparations have long been known to possess valuable anti- 

* See paper in the American Journal of Medical Sciences for July, 1844, by Wm. ML Boling, It 
D.. of Montgonierv. Ala. 

t See pap^r on the '■ Poisonous Properties of Quinia," "by Wm. O. Baldwin. M. D.. of Montgom- 
erv. Alabama, in the Ameican Journal of Medical Sciences, 1847. Also in the Medical Gazette, 
New York, for October 22d, 1681. 



TREATMENT. 193 

periodic or anti-malarial properties. The most efficacious of these prepa- 
rations, is the Liquor Potassii Arsenitis. More recently it has been found 
that the sulphites or hypo-sulphites of sodium, calcium and magnesium, 
when given in largo doses and continued for several days in succession, 
are capable of arresting the progress of ordinary periodical fevers. These 
undoubtedly act as antiseptics, neutralizing the malarial poison in the 
system. 

My own experience would indicate that they are much slower and less 
certain in their influence in preventing the recurrence of fever paroxysms 
than the quinine or its kindred substances. As I have already stated, 
abundant experience has shown that sulphate of quinia is the most relia- 
ble of all the remedies hitherto used for the interruption of the paroxysms 
or active phenomena of periodical fever, in the great majority of cases. 
The next question of practical importance is, in what doses, and at what 
times in relation to the paroxysms, can it be administered with the greatest 
certainty of success and the least liability to produce unpleasant or inju- 
rious effects upon the patient ? It is pretty generally agreed that, in all 
ordinary cases, from 0.66 to 1.33 grams (o^r. x to xx) given during each of 
the first and second days, followed by from 0.5 to 0.8 grams (gr. viii to xii) 
on the third, fourth and fifth days, is sufficient to fairly interrupt the further 
recurrence of the paroxysms. But concerning the best mode and time of 
administering the quantities I have named, you will find wide differences 
of opinion, even among the most eminent and experienced in the profes- 
sion. Some prefer to give 0.066 or 0.130 grams (gr. i or ii) every one or 
two hours, until the required quantity for the day has been taken; while 
others give the whole amount in one or two doses. Some limit the ad- 
ministration to the time of the intermission or remission, and others ad- 
minister the remedy as freely in the hot stage of the paroxysm as at any 
other time. My own clinical experience has fully satisfied me that in this, 
as in most other matters relating to the treatment of disease, the adherence 
to a medium course which avoids both extremes, is attended by the highest 
degree of success with the smallest ratio of casualties or unpleasant effects. 
Consequently, I prefer to divide the whole amount to be given in the 
twenty-four hours into three doses, and give one on the decline of a par- 
oxysm, another in the middle of the intermission or remission, and the 
third an hour before the access of the next expected paroxysm. My 
reasons for preferring this method are: first, as it is during the intermission 
or time between the paroxysms, that the exciting cause (whatever its 
form or nature may be) is being re-developed in the system and is re-accu- 
mulating its influence upon the properties of the blood and tissues, 
which is to eventuate in the re-establishment of another paroxysm; so 
the remedy that is expected to either neutralize or counterpoise the action 
of this agent, should be most actively present in the system at the same 
time if we would afford it the best opportunity for successful action. 
Second, from the sweating stage or decline of one paroxysm to the time 
for beginning the next, the stomach is less irritable, and consequently very 
much less likely to reject the medicine by vomiting, and the nervous cen- 
tres less likely to be unpleasantly disturbed, than in the stage of high 
excitement during the paroxysm. Third, the end sought, namely the effec- 
tual arrest of the active paroxysms of the disease, is obtained with greater 
uniformity by so administering the remedy that its effects are continued 
evenly through the intermission, and are existing in full activity at the 
time a paroxysm might be expected to recur. I think the same reasons 
apply to the administration of all the anti-periodic vegetable alkaloids. 
It is true, however, that the use of the quantity of quinine 1 have indi- 
13 



194 PERIODICAL FEVERS. 

cated during the first five days of the treatment, will very generally arrest 
the progress of simple intermittents, whether the amount to be given each 
day is administered in one dose or divided into ten or fifteen. And if 
the treatment I have suggested for mitigating the severity of the hot 
stage of the paroxysm be judiciously applied in the remittent cases, it will 
carry the decline as near an intermission as possible, and make the action 
of the anti-periodic almost as certain to arrest the progress of the disease 
as in the simple intermittents. 

In addition to the measures I have already indicated, the practitioner 
should always give careful attention to the functions of the abdominal 
viscera, including the kidneys. Local irritations and perversions of func- 
tion should be relieved by mild anodynes and alteratives; and secretion, 
especially of the kidneys, well sustained by diuretics, when indicated bv 
scantiness of the urine. Due attention to these items need not interfere 
in any degree with the prompt and proper use of the anti-periodics. When 
you have fairly interrupted the further recurrence of febrile paroxysms, 
whether it has required three or five or seven days, the disease under which 
your patient is laboring is by no means completely cured. The blood is 
still deficient in red corpuscles; the tone of the nervous and muscular 
structures is still below the normal standard; and the molecular changes 
required for healthy secretory action in the important secretory organs, 
are unsteady from the altered affinity between the secretory cells and the 
elements of the blood. Consequently, if the treatment is suspended here, 
as is too often the case, the patient is left in the most favorable condition 
for a relapse. It is better, therefore, that you should always give careful 
attention to the third object of treatment, which I stated to be the restor- 
ing of the constituents of the blood to their natural proportion, and the 
properties of the tissues, regulating molecular movements, to their natural 
condition. For this purpose, as soon as the active paroxysms of the fever 
are interrupted, the patient needs to be continued on a plain, nutritious 
diet; he may begin passive, moderate exercise in the open air, but should 
be careful to avoid fatigue of mind orbodv; avoid exposure to the damp- 
ness of the morning and evening, while the dew is rising or falling; and 
take such medicines as will promote the general tonicity of the tissues, 
and the reproduction of the red corpuscles of the blood, and maintain 
healthy action of the more important secretory organs. One of the best 
combinations for accomplishing these objects, is the following: 

~fy Quiniae Sulphatis 4.00 grams 3i. 

Ferri Citratis 4.00 " 3i. 

Extracti Hyosciami 2.00 " 3ss. 

Extracti Nucis Vomicae 0.6(> " gr. x. 

Mix. Divide into thirty gelatine capsules or pills, of which one 
should be given before each meal time, for the first week ; one before 
breakfast and dinner the second week ; and one before breakfast only 
during the third week. 

Another excellent formula, which I have used for many years as a sub- 
stitute for the one just given, is as follows : 

^ Extracti Cornus Floridae 4.00 grams 3i. 

Ferri Sulphatis 2.00 " 3ss. 

Extracti Hyosciami 2.00 " 3ss. 

Strychnias Sulphatis 0.06 " gr. i. 

Mix. Divide into thirty gelatine capsules or pills, of which one may 



TREATMENT. . 195 

be o-iven just as often, and continued in the same manner* as those of 
the preceding formula. 

Your knowledge of the therapeutic action of the several ingredients in- 
cluded in those formulae, enables you to see that I have in each a soluble 
salt of iron to aid in the formation of red corpuscles ; tonic doses of an 
anti-periodic and nerve tonic in the quinine and nux vomica of the one, 
and the cornus florida and strychnia of the other, to hasten the recovery 
of a natural degree of general tonicity ; and hyosciamus to soothe the sen- 
sitiveness of the gastric mucous membrane and of the tissues generally. 
Seeing thus clearly the therapeutic elements you need to combine to 
effect the improvements needed by your patient, an adequate knowledge 
of materia medica and therapeutics will enable you to make a score of 
formulae, each capable of accomplishing the objects you desire, but with a 
variable degree of efficiency. If the patient for which you are prescrib- 
ing has already become quite pale from impoverishment of the blood, he 
may derive much benefit from some of the phosphatic compounds. Four 
cubic centimetres, or a teaspoon ful, of the syrup of lacto-phosphate of 
calcium, or of iron ; or the same quantity of the compound syrup of hypo- 
phosphites of sodium, calcium and iron, may be given after each meal, in 
addition to the capsules, or pills, before the meals. Ag;ain, in many of 
the patients you will find a constant tendency to constipation, which may 
be readily obviated by adding to either of the formulae I have given, such 
proportion of gum aloes and pilulae hydrargyri as will give from 0.015 to 
0.020 grams (gr. ^ to ^) in each capsule or pill. In cases presenting enlarge- 
ments of the spleen or liver, or both, continuing after the patient is well 
recovered in other respects, I have found no remedy more certainly bene- 
ficial than the chloride of ammonium, given in doses of from 0.33 to 0.50 
grams (gr. v to viii), three or four times a day. It was recommended for 
this purpose by Dr. John Eberle, in his work on the practice of medicine, 
more than half a century since. It may be most conveniently adminis- 
tered in solution with syrup of liquorice. The practice of giving patients, 
while convalescing from malarious fevers, various compounds called 
"bitters" which was much in vogue in former times, and is by no means 
wholly abandoned yet, is a very pernicious one, and should be condemned 
by every intelligent physician. These compounds are usually made up 
of some bitter barks or roots mascerated in wine, whisky, or diluted alco- 
hol, and of such strength that patients usually take a table-spoonful or 
two, from one to three times a day. The barks and roots generally used 
are moderately tonic and unobjectionable ; but the amount of alcohol 
taken in all such preparations is sufficient to produce a perceptible dimin- 
ution of the interchange of carbonic acid gas for ox}^gen by the blood in 
the lungs, and to retard capillary circulation by its anaesthetic influence on 
the vaso-motor nerves ; effects that much more than counter-balance all 
the good derived from the bitter principles incorporated with it. The time 
has been when it was supposed that alcoholic liquors were, in themselves, 
more or less preventive or prophylactic, of malarious attacks. But experi- 
ence, both in civil and military life, has shown the fallacy of that opinion. 

If there are any who still entertain such a belief, or are in doubt on the 
subject, I would refer them to the results of an experiment tried on a 
large scale in connection with our army of the Potomac during the late 
war, as related by Dr. Frank H. Hamilton, of New York, in his " Treatise 
on Military Surgery and Hygiene," from page 70 to 75, inclusive. Having 
said what I deem necessary in regard to the ordinary intermittent and 
remittent varieties of malarial fever, I must reserve the consideration of 
the more malignant or pernicious variety of cases for another lecture hour. 



196 PERNICIOUS FEVERS. 



LECTUEE XXII. 

Periodical Fevers Continued— Pernicious Fevers; their Varieties, Symptoms, Pathology and 
Treatment. 

GENTLEMEN : The word pernicious is now quite generally used to 
designate a class of cases of malarial fever, which, though differing 
much from each other, yet exhibit a common tendency to destroy life 
within a short period of time. These cases were formerly called malignant 
by some, and congestive by others. They were much more prevalent during 
the first two or three generations, after the settlement of the more highly 
malarious districts of our country than at the present time. 

Dr. Drake tells us they are found most frequent between the parallels 
of thirty-one and thirty-three degrees, which includes that belt in the 
Southern States comprising the rice fields, the cane brakes, and the 
borders of streams and bayous opening into the Gulf of Mexico. Accord- 
ing to Dr. Drake, the next most common place to find them is along the 
Red River region of Louisiana, and the southern border of Lake Michi- 
gan, from Chicago around to St. Joseph. In the early settlement of the 
country they were quite common in the latter region, but with increase 
of population and its consequences they have become rare. 

In Europe they have long been familiar with this variety of malarial 
fever, in some portions of Holland, Turkey and Austria, and also on the 
western coast of Africa. These are the regions where it most frequently 
occurs, and consequently where its peculiarities are most familiar to the 
profession. 

You will remember that in speaking of the modus operandi of malaria 
on the human system, I deviated from the opinions most commonly 
expressed on this subject, which are, that malaria, whether organic or inor- 
ganic, produces its primary impression upon the nervous structures 
through the medium of the blood. Instead of this, I claimed that its 
presence in the blood produced a primary and direct effect on the ele- 
mentary properties common to all the tissues ; namely, susceptibility and 
vital affinity; and that the nervous disturbance was only a part of this 
more general action. I further explained that it primarily caused an 
increase of the general susceptibility or excitability, coincident with a 
decided diminution of the vital affinity by which the tonicity of the tissues 
and the atomic movements are controlled. In speaking yesterday of the 
symptomatology of periodical fevers, I explained that the difference 
between the ordinary and the pernicious paroxysm was the more profound 
depression of the vital affinity in the latter. Owing either to the intensity 
of the exciting cause (malaria) or some peculiarity of the individual, the 
depression of that property is so great as to endanger an actual arrest of 
capillary circulation and molecular changes as they occur in the processes 
of secretion, nutrition, and disintegration; and hence the extreme danger 
of actual suspension of life in the paroxysm. Or, if reaction does take 
place, it is liable to be incomplete, leaving the circulation, molecular 
changes, and temperature of some of the parts still depressed, even 
through the intermission. The essential pathology of the pernicious chill 
therefore is, that the play of vital affinity is so far overcome as to make 



VARIETIES. 197 

the restoration of the natural atomic or molecular relations between the 
constituents of the blood in the capillaries and the organized tissues 
extremely difficult. This being the essential feature of the disease, it is 
necessarily dangerous, because whenever the properties of the tissues 
become so involved that they lose their inherent power to attract new 
atoms from the blood and return old ones, as in the natural processes 
o( secretion, nutrition, etc., there is not only imminent danger of the ces- 
sation of life, but there is also great difficulty in obtaining any effect from 
the administration of remedies. 

In some cases in which reaction takes place, it is not complete or uniform 
in all parts of the body and extremities. The parts most frequently left 
pale and cold after the general reaction, are the fingers, toes, tip of the 
nose, and lobe of the ear. Such failure in any part, however limited, 
should be regarded as indicating the return of another and still more dan- 
gerous paroxvsm. 

Owing to the different degrees of intensity in the action of the malarial 
poison, or to the difference in the susceptibility of the several groups of or- 
gans, or to both, the cases classed as pernicious present considerable diversity 
in their symptoms and progress. For clinical purposes they may all be ar- 
ranged in five groups, namely: the comatose, the spasmodic, the pulmonary, 
the choleraic and the algid. This number might be reduced by uniting the 
first two groups in one, calling it the cerebro-spinal. In the first group 
here mentioned, the force of the morbid impression falls upon the brain, 
or more particularly upon the cerebral hemispheres, and so far suspends 
their function as to render the patient unconscious or comatose from the 
very beginning of the paroxysm. As these cases progress the coma may 
become hourly more profound, the face pale, the temperature low, pulse 
feeble, respiration irregular, and pupils dilated, until death supervenes. 
Dr. Hertz, in Ziemssen's Cyclopaedia, speaks of cases that are not only 
perfectly unconscious, but have reached a stage of apparent suspension 
of the functions of life so as to appear dead. He speaks of a man who 
was actually supposed to be dead, and taken to the morgue for examina- 
tion; but some signs of life being discovered he was returned to his bed, 
where subsequent reaction took place and he recovered. Such cases of 
apparent death are rare. In some of the cases in which a comatose con- 
dition presents itself, a partial reaction soon takes place, in which the face 
becomes deeply suffused, the head and trunk hot, pulse more full, and res- 
piration hurried. In some of these cases the coma gives place to wild de- 
lirium, which may end either in the supervention of sleep and an intermis- 
sion, or the return of coma, general paralysis and death. 

For practical or therapeutical purposes it is important to distinguish the 
cases in which, at least, partial reaction occurs, from those just previously 
described. The one is accompanied by febrile reaction, with fullness of 
the cerebral vessels, while the other remains cold, the pulse weak, vacil- 
lating and irregular, yet both are comatose. In the second group of cases, 
which I called spasmodic, the force of the disease appears to fall upon the 
spinal cord and medulla oblongata. In these, the paroxysm is ushered in, 
not with coma, but with severe muscular contractions, either continuous 
as in tetanus, or paroxysmal, as in convulsions. 

The latter generally occurs in children, while in adults the muscular con- 
tractions are more continuous, causing the muscles at the back of the neck 
and upper part of the spine, on one or both sides to become rigid, retract- 
ing the head, and giving the patient much the same aspect as in cerebro- 
spinal meningitis. A case of this kind, in the person of a young woman, 
came under my care many years since in the Mercy Hospital. I saw her 



198 PERNICIOUS FEVERS. 

first immediately after her admission, when in the paroxysm. She ap- 
peared entirely unconscious; the head retracted and turned to the left from 
rigid contraction of the muscles on the posterior and left side of the neck; 
face and skin generally congested and bluish; extremities cold; pulse soft 
and variable in beat; respirations increased in frequency but variable; and 
pupils nearly natural. As I could get no history of the case I regarded it 
as one of congestion of the cerebro-spinal centres, and directed treatment 
accordingly. On returning to the hospital a few hours later, I was sur- 
prised to find the patient conscious, the rigid muscles relaxed, the head 
freely movable, and the patient comparatively comfortable. I then learned 
sufficient facts concerning the history of the attack to satisfy me that it was 
altogether of malarial origin, and at once commenced giving 0.33 gram 
(gr. v) doses of quinine every two hours, and continued until 2.00 grams 
(gr, xxx) had been taken, when the time was lengthened to six hours. 
No further paroxysms recurred, and the patient soon recovered. There is 
much danger in this class of cases that the muscles of respiration may 
become so involved in the rigid contractions as to suspend the motions of 
the chest, and of course suspend also the life of the patient. 

In the third group of cases the force of the disease, instead of falling 
upon the brain or spinal cord, is manifested chiefly in the respiratory or- 
gans, and the patient, on going into the paroxysm or chill with its general 
phenomena of depression, feels great oppression across the chest; the 
breathing becomes laborious, the finger-nails blue, the lips leaden, 
and the pulse frequent and feeble, with impairment of circulation in 
the cutaneous surface. While the mind remains clear, though often 
inclined to drowsiness, the stagnation in the pulmonary capillaries and 
consequent dyspnoea increases rapidly. At first there is a universal mix- 
ture of moist and dry rales passing rapidly into the sub-mucous and 
mucous rhonchi, all over the chest from the clavicles to the diaphragm, 
posteriorly and anteriorly. 

The accumulation in the lungs is sometimes so rapid that the air ceils 
become literally overwhelmed by compression and edematous infiltration 
in three or four hours, shutting the air off so completely that the patient 
dies directly from suffocation. One case of this kind came under my ob- 
servation many years ago, that terminated fatally in about eight hours. 
More recently, in consultation with another physician, I saw a case almost 
equally rapid in its progress, but which was arrested, and recovery took 
place. 

In the fourth or choleraic group of cases, the force of the disease seems 
to fall more directly upon the digestive organs, causing in addition to the 
general depression and coldness, great epigastric distress and restlessness, 
with frequent turns of vomiting and purging, intense thirst, dryness of the 
mouth and fauces, coldness and blueness of the surface and extremities, and 
weakness of voice, constituting a group of symptoms so closely resem- 
bling a severe attack of epidemic cholera, that the case would be readily 
classed as such if the latter disease should happen to be prevailing in the 
community at the same time. Generally, however, there are less muscular 
cramps, and the discharges less like rice water in appearance than in chol- 
era. In some of this group of cases, especially in warm climates, and 
when th 1 "* pernicious character manifests itself after one or more paroxysms 
of a milder grade, more or less haemorrhage accompanies the stage of ex- 
haustion. 

I recollect an instance occurring outside of the city limits, twenty years 
ago, in the latter part of the summer, where a man, past the middle period 
of life, had a periodical fever for four or five days, accompanied by loose. 



SYMPTOMS. 199 

ness of the bowels, and which ended in a paroxysm of extreme depression, 
during which he had three or four copious discharges of dark gruinous 
blood, and in less than five hours he was in a state of complete collapse, 
and soon died, apparently from the direct effects of the haemorrhage. 

Haemorrhage in these cases may take place from the gums, from the 
mouth, and from the nasal passages, the renal organs, or into the 
subcutaneous tissues, just as we see sometimes in malignant cases 
of the eruptive fevers. I saw, not two weeks since, a case of measles 
where the disease manifested itself in this malignant form. A general 
hemorrhagic tendency was developed so early that on the second day of 
the eruption there was more or less extravasation into the tissues, and an 
oozing of blood into the mouth, and the patient died within twenty-four 
hours from the time I saw her, which was on the evening of the third day 
of eruption. Jt was a young woman in the vigorous period of adult life. 

A similar pathological condition is occasionally seen in the more malig- 
nant cases of all the varieties of idiopathic fever. 

I have now described briefly the comatose and the spasmodic cases 
which involve prominently the cerebro-spinal nervous centres, the pul- 
monary, or such as endanger life from suspension of the respiratory func- 
tion, and the choleraic, involving most prominently the digestive organs. 
The last cases described, accompanied by haemorrhage, are by most writers, 
placed in a separate group called the haemorrhagic. There is another 
variety still, that is known as pre-eminently the cold or algid group. Pri- 
marily all are more or less cold, but there is a class of cases where the 
patient becomes almost at once cold and blue, and ultimately his organic 
functions cease without any specific determination to one important organ 
more than another, unless it be to the cutaneous surface in the form of 
copious cold sweating. And even the post-mortem examination in these 
cases reveals nothing more than a paler and drier state of the tissues than 
natural. When death has taken place in the comatose groups of cases, 
the post-mortem examination reveals more fullness of the vessels of the 
brain, with more or less cedematous infiltration into the cerebral substance. 
In the spasmodic or convulsive group similar appearances are found in the 
spinal cord or medulla oblongata, or both. In the pulmonary group the 
predominant post-mortem appearances are passive engorgement of the 
vessels and oedema of the tissue of the lungs. True hepatization or other 
inflammatory changes are very seldom seen. In the choleraic groups of 
cases the chief post-mortem changes are increased fullness of the vessels, 
with softening of portions of the mucous membrane of the alimentary 
canal, with a similar condition of the spleen, and, less notably, of the liver. 

All these post-mortem changes point directly to certain pathological 
conditions, such as general impairment of tonicity in the tissues, including 
especially the coats of the blood-vessels, and ready passive exudations 
wherever local determinations take place. These are shown by the copious 
sweating from the skin, the still more copious serous and hemorrhagic dis- 
charges from the internal surfaces, the vascular fullness with oedema of 
the brain and lungs, and the actual reduction of temperature. In regard 
to the latter, Dr. Hertz mentions a case in which the clinical thermometer 
gave only 31° C. (88° F.) in the mouth, 30° C. (86° F.) in the anus, and 
28.8° C. (84° F.) in the axilla. Such reduction of temperature, as well as 
the whole assemblage of changes I have described, clearly indicate a great 
impairment of tonicity, including muscular contractility, and of molecular 
changes and innervation. 

If these views, sustained alike by clinical observation and post-mortem 
examinations, are correct, they furnish two leading and important indica- 



200 PERNICIOUS FEVERS. 

tions for treatment. First, to bring about general and uniform reaction by 
the prompt use of such means as will most efficiently increase the tonicity 
of the tissues, the molecular changes, and the vaso-motor sensibility. If 
we succeed in this, and thereby conduct the patient safely to the com- 
mencement of a period of remission or intermission, the second indication 
is to bring him, as speedily as possible, so fully under the influence of 
some anti-periodic as to prevent the supervention of another paroxysm. 

In endeavoring to fulfill the first indication, it has been, from the earliest 
period in the history of the disease, a common practice to endeavor to 
establish reaction and warmth by administering large doses of hot stimu- 
lating remedies internally, and applying all kinds of heating and irritant 
applications externally. Hot whisky or brandy punch, with or without the 
addition of pepper, has been given most liberally, with external frictions, 
sinapisms, hot bricks, hot corn, bottles of hot water, and hot baths, and 
yet without the slightest beneficial effect on the patient. 

Dr. Daniel Drake, in his valuable work on the Topography and Diseases 
of the Interior Valley of the Continent, states that he has seen the skin 
made red by hot frictions without the slightest effect on the temperature. 
In one case he saw the patient immersed in a hot bath containing a liberal 
quantity of salt, mustard and whisky ; and in another the patient was en- 
veloped in cloths or sheets wet with an infusion of Peruvian bark as hot 
as could be borne, and covered with oiled silk to prevent evaporation, but 
in neither was there any improvement in the circulation or the tempera- 
ture. And he states as the result of his extensive personal investigations, 
that both external heat and the internal use of what are called alcoholic 
stimulants, are absolutely useless in the depression of a true pernicious 
paroxysm of malarial fever. From what we now know of the effects of 
alcohol as an anassthetic to nerve sensibility, and direct retarder of mole- 
cular changes and capillary circulation, we should not only expect no 
benefit, hut positive harm from its use in these cases. Under the theory 
of internal congestion, especially of the portal system of vessels, bleed- 
ing, large doses of calomel, and various kinds of emetics have been tried, 
but with no encouraging results, except in a few cases, when an emetic of 
salt and mustard appeared to aid in establishing reaction. 

Dr. Milne Edwards many years ago demonstrated very clearly, by an 
ample series of experiments upon the living animal, that heat diminishes 
the general tonicity and relaxes the contractile tissues of the body, and 
that cold increases both by bringing the atoms closer together and strength- 
ening the play of vital affinity. 

The results obtained by Dr. Edwards have been fully confirmed by later 
observations; and whether you agree with me that malaria acts directly 
upon the elementary properties common to all living tissues, or indirectly 
through a primary paralyzing influence on the vaso-motor nervous system, 
as suggested by most writers, the}^ point directly to the sudden and tem- 
porary application of cold as the most rational and efficient means we pos- 
sess for arousing nerve sensibility, capillary circulation, molecular move- 
ments, and, as a result, an increase of temperature. I have repeatedly 
seen this power efficiently displayed in the treatment of cases of opium 
poisoning. In the case of a little child to whom the mother had given an 
overdose of laudanum by mistake, I was called in the middle of the night, 
and as I entered the room the child appeared to be breathing out its last 
gasp. I immediately caught a cup of cold water and suddenly dashed a 
part of it on the child's face and chest, which aroused two or three quick 
and full inspirations, followed by shorter and shorter ones, until another 
apparent stop; another dash of cold water renewed them, and for more 



TREATMENT. 201 

than three hours I sat by the child repeating the dash as often as the re- 
spiratory movements failed, during which the poison was so far eliminated 
and the nervous sensibility restored that it was safe to leave the patient. 

In using the dash of cold water for the purpose of establishing general 
reaction from the cold stage of pernicious fever, the patient should be 
stripped, and several gallons of cold water suddenly dashed over the head 
and trunk of the body, then quickly rolled up in warm dry flannel blank- 
ets for thirty minutes. If there is not a decided improvement in the pulse 
and temperature at the end of that time, unwrap him and repeat the dash, 
following it by the warm blankets as before. This process may be repeat- 
ed three or four times, if necessary, but in most of the instances in which 
it has been tried, one or two repetitions have been sufficient. I do not 
recommend to you this method of treating the pernicious chill on mere 
theoretical grounds, for it has had the sanction of direct clinical experi- 
ence. So early as 1830, Dr. Fearn, of Huntsville, A'abama, one of the 
most eminent and successful practitioners in the Southern States at that 
time, adopted the practice with such success as to attract much attention 
and to win many followers in the South. He was residing in the belt of 
country most favorable for the development of this variety of malarial 
fever, and at a period of time when it was much more prevalent than it 
has been in later years. Only two cases have come directly under my 
observation in which the practice was adopted, and in both the result was 
favorable. One of these occurred more than twenty years since. The 
patient was a young woman in a family of hydropathic faith, and when 
they were told by the attending physician, and myself in consultation, that 
the patient might not live until morning, they took the case into their 
own hands, wrapped her in cold wet sheets for a pack nearly half an hour, 
then changed to warm dry blankets, from which time she began to im- 
prove, and in less than eight hours she had safely entered the stage of 
intermission. 

Very recently, Dr. J. P. Davidson, of New Orleans, in a valuable paper 
read to the New Orleans Medical and Surgical Association, on Pernicious 
Fever, has added his testimony in favor of the cold douche in the most 
emphatic manner.* 

While I have no doubt but that the sudden and alternate application 
of the dash of cold wate«r and dry warmth constitutes one of the most effi- 
cient methods of establishing reaction, there are other remedies of real 
value, especially in some of the groups of cases I have described, and 
which may be used either alone or in conjunction with the process just 
indicated. For instance, in those cases of the comatose variety where a 
partial reaction has taken place and the face is deeply flushed and the 
head hot, apply an ice cap to the head and back of the neck. In other 
cases, where they are equally comatose but pale and cool, instead of the 
ice cap bring the patient's head over a tub, and with a pitcher filled with 
tepid water pour a douche of two or three quarts of water over the occi- 
put, repeating it once in from half an hour to an hour, and it will consti- 
tute one of the most efficacious means of relief. The same means are 

*See Paper on Pernicious "Fever, by J. P. Davidson M D., in the New Orleans Medical and Sur- 
gical Journal for February, 1S80. On pages 756 and 757, Dr. Davidson uses the following language : 
'• In cases oi the algid form ot the disease, in which the symptoms of codapse mannest thems ives 
early. I know ol no plan ot ireatmen' calculated to meet the exigencies of the case equaL to the cold 
douche.'' * * * * "No time is to be lost in relieving the patient of the lesion of innerv i tion 
and bringing about reaction. Delay in experimenting with stimulants, sinapisms, frictions, etc.. is 
time thrown away, and will commonly disappoint the expectations of the physician. While the 
depressed condition of the hear 's acio'n continues, with the serum of th blood exuding through 
the paralyzed capillaries of the whole mucous lining of the bowels, and the copious transudation 
through t r> skin, exhausting the patient, and deepening the collapse, calorification is difficult to 
restore; all means, thereio- e, of arousing the energies of the nervous system short ot the shock 
produced by the cold douche, properly administered, will avail but little." 



202 PEEIODICAL FEVEES. 

applicable to the neck and spine, in the group of cases described as spas- 
modic or convulsive, and to the chest in those cases where the lungs are 
involved. In the choleraic cases, accompanied by great restlessness, fre- 
quent vomiting and purging, with cold sweat, much collateral advantage 
may be gained by the judicious use of morphia and atropia hypodermical- 
ly. If the heart's action is very feeble the injection of morphia and atro- 
pia may be alternated with suitable doses of strychnia. In the purely 
algid cases, as I have described them, in addition to the efficient applica- 
tion alternately of cold water and dry warmth, the prompt administration, 
either by the stomach or hypodermically, of strychnia and atropia, without 
morphine, will constitute the best treatment you can adopt. 

Atropia is one of the most reliable remedies we have for checking ex- 
cessive perspiration and increasing the blood in the peripheral capillaries, 
while strychnia is equally efficient in increasing muscular contractility, 
and thus strengthening the heart. 

If, by the means I have detailed, or any other, the reaction is estab- 
lished, and the patient approaches the period of intermission or remission, 
how can we fulfill the second indication I have named, and most certainly 
prevent another paroxysm ? I answer, by bringing the patient as rapidly 
as possible under the full influence of sulphate of quinia, which is 
very generally conceded to be more reliable for this purpose than any 
other remedy in the materia medica. For accomplishing this, 1.0 to 1.3 
grams (gr. xv to xx) of quinine should be given at once by the mouth, 
and the same quantity repeated at such intervals that three doses will be 
taken before the time for commencing another paroxysm. If the stomach 
rejects the remedy by vomiting, 2.0 grams (gr xxx) may be given in the 
form of enema, and repeated at the same intervals, as if given by the 
mouth ; or from 0.5 to 0.6 grams (gr. viii to x) may be used hypodermi- 
cally, and repeated as by the other methods. Nearly the same quantities 
should be administered the second day, and one-half as much the third ; 
after which ordinary doses with rest and proper nourishment, will 
complete the convalescence. Many have recommended much larger 
doses of the quinine than I have indicated, some giving from 2.0 
to 4.0 grams (gr. xxx to lx) at a dose, and repeating until 8.0 
grams ( 3ii ) or more, have been taken in from twelve to twenty- 
four hours. Such doses, however, have produced complete loss of both 
sight and hearing in some cases, and in others, the death of the patient ; 
and I believe them to be wholly unnecessary. All attacks of pernicious 
fever leave the patient much debilitated, and hence proper caution should 
be exercised in regard to both mental and physical exercise until health 
and strength are fully restored. 

Malarial Hazmaturia or H&morrhagic Malarial Fever. — During 
the last twenty years a form of malarial fever has been met with, more 
especially in the States bordering on the Lower Mississippi and the Gulf 
of Mexico, characterized by a chill, unusually severe nausea and vomiting, 
very rapid development of a deep yellow color, haemorrhage from the kid- 
neys and bladder, with dangerous prostration. Gases of the same form 
have, doubtless, been met with in former times and in other countries, but 
did not attract special attention until fully described by Drs. Michel, 
Osborn, Ghent, Barnes, Davidson, and others in the Southern States, and 
more recently by Dr. Berenger-Feraud, as it appeared in Senegambia and 
Cochin China. In the Southern States it has prevailed chiefly in the 
winter or cold and rainy season of the year. It generally attacks persons 
who have already become anemic from previous malarial attacks, and is 
often immediately preceded by three or four paroxysms of ordinary inter- 



TREATMENT. 203 

mittent fever.* The discharge of very dark bloody urine commences 
almost immediately after the initial chill; the matters vomited and purged 
are copious in quantity, almost as black as tar from the intermixture of 
bile, and often change to a deep green after exposure to the light and air. 
They contain no blood. The tonoue is generally coated; pulse is quick 
and weak; temperature varies from 37° to 40° C. (99° to 104° F.) and the 
discharge of blood with the urine continues until, in many of the cases, 
fatal collapse ensues. The duration of the disease may vary from twelve 
hours to as many days. 

The prognosis is xevy unfavorable. 

Post-mortem examinations show no structural changes specially charac- 
teristic of this variety of malarial fever. The stomach generally contains 
a dark fluid mixed with altered bile ; its mucous membrane is injected 
with blood and more or less tumefied ; the spleen and kidneys much en- 
la ro-ed from vascular-congestion, and the latter from hamiorrhagic exuda- 
tion. 

Treatment. — The chief indications for treatment in these cases are, 
to arrest the progress of the general fever; stop the hagmaturia, and 
restore the natural secretory action of the liver and kidneys. For 
accomplishing the two first objects, large doses of quinine, opium, and 
ordinary astringents, have been frequently used, but with very little 
success; indeed, the opium and pure astringents are more likely to cause 
suppression of urine and favor uremic poisoning than they are to do good. 

The use of the sulphite or hyposulphite of soda in full doses, is very 
strongly recommended by Dr. F. C. Fahs, of Alabama, and Dr. G. 13. 
Malone, of Arkansas. The latter claims to have treated forty-four cases 
without a single death. He gives 2 grams (gr. xxx) of the hyposulphite 
of sodium, and 4 cubic centimeters (fl. 3i.) of fluid extract of buchu dis- 
solved in 30 cubic centimeters (fJ. |i.) of water, and repeats the dose every 
three hours until the disease is arrested. While the hyposulphite is 
being; administered to arrest the general disease, the haemorrhage from the 
congested and partially paralyzed renal vessels may be most effectually 
checked and the natural secretion promoted, by giving between the doses 
of the hyposulphite, 4 cubic centimeters (fl. 3i.) of spirits of nitre and 
0.33 cubic centimeters (min. v) of oil of turpentine in a little sweetened 
water. In the beginning of the treatment if the vomiting is persistent, 
allowing the patient to drink freely of cold water until the efforts at vom- 
iting cease, has been found beneficial. The use of small and frequently 
repeated doses of fresh buttermilk or milk whey, through the whole course 
of the disease, will aid in improving the renal secretion and nourishing the 
patient. After the paroxysms of fever and the hasmaturia have been 
fairly arrested, and the hepatic, renal, and intestinal secretions restored, 
the patient may be put upon the same tonics and nutrients as I have 
already recommended during convalescence from other varieties of 
malarial fever. 

Typho- Malarial Fever. — As I explained fully when discussing the 
subject of typhoid fever, there are many localities in which the causes of 
both continued and periodical fevers exist at the same time, and are con- 
sequently exerting their influence up m the human system conjointly. 
The result is, not the production of a separate and distinct form of fever, 
to be designated typho-malarial; but simply an intermingling; of the symp- 
toms and pathological changes of the two types of fever in the same 

* Dr. Michel, of Alabama, describe^ the disease as "a malignant malarial fever, following repeated 
attacks of intermittent, characterized by intense nausea and vomiting, very rapid and" complete 
jaundiced condition of thesuriaee, as well as most of the internal organs of the body, an impacted 
gall bladder and haemorrhage lrom the kidneys." 



204 



ERUPTIVE FEVERS. 



patient. The symptoms and general progress of such cases are suffi- 
ciently considered in the 11th lecture of the present course.* The 
correct view is to regard the cases of lever occurring under such 
influences as mixed or complicated fevers. If the malarial element 
predominates, the case will be one of periodical fever, complicated by 
typhoid symptoms and tendencies. If the causes of typhoid predominate, 
the cas » will be true typhoid fever, complicated with symptoms of 
malarial influence. It is of much practical importance that the physician 
should recognize the true character of all such cases, and use conjointly 
the proper remedies for both, instead of trying to relieve one class of 
symptoms before prescribing for the other. Moderate anti-periodic doses 
of quinine should be promptly given and repeated until the symptoms 
produced by the malarious element are removed, and at. the same time the 
pathological changes of the typhoid class may be checked and ultimately 
overcome by the administration of 0.8 cubic cpntimeters (min. xii) of the 
aqueous solution of iodine every four or six hours. f In the middle and 
later stages of each case, such additional remedies should be given as the 
development of local symptoms may indicate. These have been iulJy 
detailed in previous lectures, and need not be repeated here. 



LECTURE XXIII. 

Eruptive Fevers— Their Names, History, Causes, Pathology and Anatomical Characteristics. 

GENTLEMEN : — I come now to the consideration of the third, and 
last group, or subdivision, of the acute general diseases. 

This group is called eruptive fevers* for the reason that each disease 
properly included in the group, is characterized at a certain stage of its 
progress by the appearance upon the cutaneous surface of an eruption of 
a uniform character, and bearing a certain relation to the progress of the 
general disease. The diseases included under this head are, variola with 
its modifications, varioloid and vaccina ; varicella and sudamina ; scar- 
latina ; rubeola ; rotheln ; roseola ; and miliaria. To these I shall add 
parotitis contagiosa or mumps, and pertussis or whooping-cough, for 
though neither of them have any characteristic eruption upon the surface, 
both present so many circumstances analagous to those accompanying the 
true eruptive fevers, that they can be more properly considered in this 
connection than elsewhere. 

History. — All these diseases have been known and described from the 
earliest period of medical history, although not accurately differentiated 
as separate diseases until the latter part of the eighteenth century. They 
were generally classed together as acute exanthems. Variola or small- 
pox, was, perhaps, the first to receive a separate recognition, having been 
traced in China and India to a very early period of time. It is not cer- 
tain that it was known among the ancient Greeks and Romans, but was 
introduced into Europe through the Arabians during the sixth century of 

*See pp. 90-91 of this volume. 
fSee formula on page 131. 



CAUSES. 205 

the Christian era. From that time to rhe introduction of vaccination in 
the latter part of the eighteenth century, it repeatedly spread over the 
larger part of Europe in severe epidemic form, and soon became one of 
the most dreaded of all the diseases that scourge the human race. During 
the SHtue period of time the scarlet fever, measles, diphtheria, and rotheln, 
ware included together under the names of cynanche or angina, and in the 
aggregate proved but little less destructive to life than the variola. Prior 
to the practice of vaccination by Dr. Jenner, the best English authorities 
estimate that the average annual mortality from variola in Europe was not 
less than 210,000, and in Great Britain and Ireland, at least 45,000. If 
you add to these figures the average annual mortality from the scarlet 
'fever and other members of the group, you will have abetter idea, both of 
the importance of these several diseases, and of the value of vaccination 
and other prophylactic and sanitary measures, adopted for their prevention. 

Causes. — All the diseases I have named as belonging to the class of 
eruptive fevers, except roseola, sudamina, and miliaria, arise directly from 
specific contagiums or viruses, reproduced in the bodies of the sick, and 
communicable from one individual to another, either by inhalation of an 
infected atmosphere or by inoculation. Other influences may increase the 
susceptibility of the individual to the action of the specific poison, or may 
impair his power of resistence when attacked, and thereby act the part of 
predisposing agents. The protracted influence of cold and dampness 
appears to favor the prevalence of these affections, as they are generally 
more prevalent during the cold season, including the spring and autumn, 
than in the summer. 

Such atmospheric impurities as are produced by neglect of ventilation 
and cleanliness, also favor their spread, and increase their fatality. But 
the most efficient of all the predisposing influences is that mysterious 
atmospheric condition called the "epidemic constitution," which occurs at 
variable periods of time, and during which they exhibit a persistency in 
the disposition to spread, and to search out the unprotected members of 
the community far more actively than during the years between these 
special epidemic periods. 

Aside, however, from all predisposing causes, each of the diseases under 
consideration has its own specific exciting cause, which evidently consists 
of a contagious organic substance or virus, elaborated in the bodies of the 
sick; and in some of them, as the variola, vaccina, and varicella, capable 
of isolation and examination. In the three diseases just named, the virus 
collects in fluid form, during the active progress of each disease, in vesi- 
cles and pustules in the skin, from which an abundance can be obtained 
for examination and analysis, both chemically and microscopically. In the 
exanthematous members of this group, namely, the scarlatina, rubeola 
and rotheln, the specific contagium also produces more or less inflamma- 
tion in the skin, but does not collect in fluid form in visible vesicles or 
pustules, but is eliminated with the exhalations from the skin and mu- 
cous membrane of the air passages. That each has a specific virus, and 
that it exists in the blood during the active progress of the symptoms, is 
proved, however, not only by the contagiousness of the emanations just 
mentioned, but by the ability to reproduce the disease by inoculating well 
persons with the blood of those who are sick. 

Microscopic examinations have revealed the existence of minute organic 
germs in the blood of all these contagious eruptive diseases, and in the 
virus or lymph that collects in the vesicles and pustules of variola, vari- 
cella, etc.; but the germs thus discovered do not differ in any appreciable 
degree from the bacteria and micrococci, found under many other condi- 



206 ERUPTIVE FEVERS. 

tions having no connection with these diseases. Consequently there is no 
evidence that these organic germs constitute the active contagiums on 
which these several diseases depend for their existence and propagation. 
On the contrary, there are some iacts which ohslt strongly aarainst such an 
inference. It is well known that the emanations from the skin and lungs 
of patients affected with any of the diseases under consideration, are suffi- 
ciently impregnated w T ith the specific contagious material to communicate 
the disease to others who may chance to breathe the air of a room contain- 
ing such emanations. Yet no one, I think, has been able to detect any 
germs in the exhalations from the skin and lungs of those sick, that were 
not found equally numerous in the exhalations from the same sources in 
persons enjoying good health. In the latter part of the year 1870, the 
late Dr. F. H. Davis, of this city, instituted a series of observations on the 
exhalations of patients laboring under typhoid fever, diphtheria, erysipe- 
las, scarlatina and rubeola. The organic materials in the atmosphere of 
the sick room, in the breath exhaled, etc., were collected on clean glass 
slides, moistened with pure glycerine, and submitted to thorough micro- 
scopic examination. The results were given in his inaugural theses in 
March, 1871. He found an abundance of dust particles and a variety of 
organic atoms, but nothing whatever that he did not find equally abund- 
ant on the slides exposed in the same way to the breath and the air of 
rooms occupied by persons in good health.* It is highly probable, there- 
to, e, that the true contagium does not consist of bacteria or any other liv- 
ing germs, but of a subtle fluid impregnating the serum of the blood, 
capable of collecting with such serum in vesicles and pustules, and of 
being exhaled with the aqueous vapor from the skin and lungs, and pos- 
sibly with all the excretions from the bodies of the sick. But whatever 
may be the form of the several specific contagiums that give rise to the 
eruptive fevers, the laws that govern their action upon the human system 
are more definitely ascertained, and are of great practical importance. 
When introduced into the human system, whether by inoculation, inhala- 
tion, or any other method, they require a certain period of time, either for 
self-multiplication or for effecting certain changes in the quality of the 
blood, probably for both, before any appreciable effects are produced upon 
the functions of the body. The time thus required is called the period of 
incubation. Its length is not the same in all of these affections, but 
varies from an average of five days in scarlet fever, to twelve or fourteen 
days in variola. 

The period of incubation having passed, they all present evidence of 
possessing active irritative qualities sufficient to induce the rapid develop- 
ment of a high grade of general fever, which continues from two to four- 
days before the characteristic eruptions appear upon the cutaneous surface. 
This is called the period of primary or premonitory fever. The eruption 
in each disease presents a definite stage of increase, maturity, and decline, 
which together constitute the period of eruption. At the end of the 
period of eruption, convalescence ensues, unless it is postponed by the 
severity of such local complications as are liable to occur in nearly all 
these varieties of fever. 

You perceive, therefore, that the events following the introduction of 
any one of these specific poisons, succeed each other in a definite order, 
each event occupying a definite period of time, accompanied by distinctive 
symptoms, and ending spontaneously in convalescence. 

The diseases they produce are, therefore, strictly self-limited in dura- 
tion, and one attack, as a rule, permanently destroys the susceptibility of 

*See Chicago Medical Examiner, Vol. xii, pp. 197-8. 



PATHOLOGY. 207 

the system to future attacks of the same disease. With the exception of 
variola, all the diseases under consideration occur far more frequently in 
childhood and youth, than at any later period of life, yet no age is en- 
tirely exempt from liability to an attack. Neither sex nor nationality 
appear to exert any influence over the susceptibility to this class of diseases. 

Patholoijij. — What I have been stating to you concerning the efficient 
causes of eruptive fevers, leads naturally to an inquiry into their general 
pathology, or the nature of the morbid processes that take place during 
the successive stages of their progress. That the specific contagium, how- 
ever small the quantity primarily introduced, enters the blood and there 
undergoes an increase more or less rapid during the period of incubation, 
is undoubtedly true. That it circulates with the blood throughout all the 
living structures, and when sufficiently developed, produces a direct irri- 
tative efFect, thereby morbidly exalt ng the susceptibility and disturbing 
the vital affinity in such a way as to pervert the molecular changes con- 
cerned in nutrition, disintegration and secretion, coincidently with dis- 
turbance of innervation and temperature, is cleariy evident from the 
uniform establishment of general irritative fever prior to the appearance 
of any local inflammations in the skin or elsewhere. 

Yet a careful clinical study of the symptoms characterizing the further 
progress of each case, shows that, in addition to this general irritative 
action, the exciting cause or poison possesses a special affinity for the 
cutaneous tissue and certain parts of the mucous membrane of the respira- 
tory passages, causing it to accumulate therein with greater or less rapidity, 
and to establish at each point of accumulation an inflammation of a grade 
peculiar to itself. In the ordinary cases of variola, varioloid and varicella, 
the accumulation of these poisons in the cutaneous tissue, is so rapid that 
by the third or fourth day, the blood has become free from their presence, 
and consequently the general fever subsides coincidently with the appear- 
ance of the eruption, or points of local inflammation on the surface; and 
if any renewal of fever takes place during the subsequent progress of the 
case, it results from the extent and intensity of the local inflammations, and 
not from the action of the primary poison in the blood. In scarlatina, 
rubeola and rotheln, the exciting cause or contagium is attracted to the 
cutaneous tissue less rapidly, and the blood does not become free from the 
poison until the cutaneous and other local inflammations have reached 
their climax, which is from three to five days after they first become visible. 
Consequently, the general fever, instead of ceasing at the time of the first 
appearance of the points of inflammation on the surface, as in variola, con- 
tinues unabated until such local inflammations or efflorescences have 
reached their full maturity, and then both decline together, accompanied 
by a more or less complete exfoliation of the cuticle, and leaving the sys- 
tem free from the specific poison. The contagiums of variola and varicella 
manifest very little affinity for, or tendency to find lodgments in, any 
other than the cutaneous structure. A few points of lodgment and con- 
sequently of pustular or vesicular inflammation are seen in the mucous 
membrane lining the mouth and fauces in a large proportion of the cases. 
They app2ar at the same time and pass through the same stages as the 
eruption on the surface. But the contagiums of scar.atina and rotheln 
manifest quite as much affinity for the mucous membrane of the fauces, 
pharynx and nostrils, with the contiguous glands, as for the cutaneous 
tissue; and in many cases establish in these parts a dangerous degree of 
inflammation; while that of rubeola selects for its special lodgment and 
irritative action, the mucous membrane of the nostrils, trachea, and larger 
bronchial tubes, in addition to'the skin. 



20S ERUPTIVE FEVEES. 

In a large majority of the cases of all varieties of eruptive fever, the 
quantity and quality of the contagium developed in the system of the 
patient is such that the whole of it finds first lodgment in, and subse- 
quently complete exit through, the surfaces I have mentioned, and an 
early convalescence is established. In a smaller number the quantity or 
quality of the poison is such that the extent and intensity of the inflam- 
mation in the skin, fauces, and glands of the neck, may be sufficient to 
endanger the life of the patient, as in confluent variola and anginose scar- 
latina. Jn a still smaller number of cases, owing either to the quantity and 
quality of the poison, or to some prior defect in the properties of the tis- 
sues, the specific poison fails to impinge or find complete lodgment in 
the cutaneous and other tissues I have named, consequently a large part of 
it remains in the blood, not only perpetuating the general fever, but caus- 
ing so rapid an impairment of the quality of the blood itself as to speedily 
endanger the life of the patient. These constitute the class of cases usually 
called malignant. You thus see that we may have three groups of cases 
in each of the eruptive fevers, namely, the simple, the intensely inflam- 
matory, and the malignant, hi reference to variola, authors designate 
the first of these groups as distinct, or discrete small-pox ; the second as 
confluent, and the third as malignant. In reference to scarlatina, the cases 
in the first group are called scarlatina simplex ; those in the second, scar- 
latina ano-inosa ; and those in the third scarlatina maligna. The cases be- 
longing to the first group of all the varieties of eruptive fever, uniformly 
tend to convalescence and early recovery. Those classed in the second group 
tend towards recovery or death, in proportion to the extent and intensity of 
the local inflammations, and the prior constitutional condition of the pa- 
tient. In variola, for instance, the number of points of local inflammation or 
pustules on the surface, ma}'- be so great that in the progress of develop- 
ment they touch margins, and become continuous, one with another, over 
a very large part of the cutaneous surface, causing them to be termed con- 
fluent cases. The secondary fever and copiousness of the suppurative 
process are sufficient, in many of these cases, to produce fatal exhaustion 
before the suppurative stage is completed. Another source of danger in 
these cases is the absorption of septic matter from the suppurative sur- 
faces, the re-poisoning of the blood, and the consequent rapid and fatal 
exhaustion of the patient. If, however, the confluence of the pustules is 
not general, but limited mostly to the face and hands, and the constitu- 
tional condition of the patient is good, the tendency will be towards re- 
covery. In scarlatina the cases included in the second group will be 
dangerous to life, in proportion to the extent and intensity of the inflam- 
mation of the fauces, tonsils and glands of the neck. The swelling of 
these parts may be sufficient to so obstruct both respiration and deglu- 
tition as to cause a fatal result during the first three or four days. Or, 
with less tumefaction, there may follow such a degree of ulceration and 
persistent suppurative action in the fauces, nostrils, etc., as to cause a 
slower but none the less fatal degree of exhaustion. There are many 
cases, however, belonging to this group, in which the local inflammation is 
less severe, the ulcerations limited, and sufficient nourishment can be taken 
to sustain the strength of the patient until convalescence ensues. The 
cases included in the malignant group of eruptive fevers, are those in 
which the specific cause accumulates in the blood to such a degree that the 
latter is incapable of maintaining the mutual relations between it and the 
several structures of the body ; consequently the tonicity of the latter 
becomes rapidly impaired, molecular changes fail, nervous sensibility is 
blunted, and all the phenomena of life soon cease. In many of these 



ANATOMICAL CHARACTERISTICS. 209 

cases petechia] or hemorrhagic exudations and haemorrhages precede the 
fatal result. By attempting to classify all cases of eruptive fever into the 
three groups 1 have named, you must not infer that there is any well de- 
fined or broad line of difference separating these groups. On the con- 
trary, at the bed-side, you will find the severer cases of the first group so 
closely approximating the milder ones of the second, that you will often 
be in doubt as to whether you should assign a given case to one or the other. 
The same is true if you compare the most severe cases included in the sec- 
ond group with the least malignant of those in the third. Having ex- 
plained, as fully as practicable, the views I entertain concerning the 
causes, pathological conditions, and tendencies of those acute general 
diseases classed as eruptive fevers, I will next direct your attention to the 
anatomical characters or structural changes belonging to each. 

Anatomical Characteristics. — The most constant and distinctive ana- 
tomical or structural lesions found in these fevers, are developed on the 
cutaneous surface in the form of eruptions. 

These eruptions are presented in three distinct primary forms, each 
form having its own structural peculiarities, and its own modes of further 
development. The first form is primarily a papule or small hard pimple 
between the cuticle and cutis vera, sufficiently elevated to be readily 
detected by the touch, and on the apex of which may be seen a minute 
vesicle filled with transparent serum or lymph. These, at a certain stage 
of their progress, become inflamed and suppurate, by which the serum 
they contain is changed to a purulent fluid, the hard base much increased 
in circumference, the vesicle flattened and depressed or umbilicated in 
the center, constituting a mature pustule. The fevers characterized by 
this form of eruption are the variola, varioloid, and vaccine. 

The second is that of a true vesicle produced by sufficient inflammation 
at a given point in the cutis vera to cause an exudation of serum and 
elevation of the cuticle into a transparent vesicle, larger in circumference 
and without the hard base that belongs to the pustule. The only erup- 
tive fevers charactered by this vesicular form of eruption are the varicella 
and sudamina. 

The third appears in the form of small red points or spots, without the 
hard elevation belonging to the first variety, or the vesicle of the second. 
There is no exudation of serum sufficient to elevate the cuticle, nor sup- 
puration, in any part of their progress. Remaining as simple red points 
or spots throughout their course, they are called exanthems, or more pop- 
ularly the rash. They may be pretty uniformly diffused over the surface 
and so numerous as to cause general redness, as in scarlatina; or they may 
be aggregated in clusters, leaving the intervening parts of the skin natu- 
ral as in rubeola. The fevers characterized by this form of eruption are 
scarlatina, rubeola, rotheln, roseola, and miliaria; hence they are prop- 
erly styled acute exanthematous diseases, as distinguished from those I 
have named as vesicular and pustular. 

An accurate knowledge of the special characters of each of these forms 
of eruption is of much importance as an aid in the diagnosis of the several 
diseases in which they occur. 

The pustule commences by simple congestion or accumulation of blood 
in the capillaries of the papillae of the corion in a very small spot of the 
skin. This is quickly followed by exudation of minute specks of serum 
in the connective tissue and swelling of the epithelial cells of the rete 
Malpighii. It is this exudation and enlargement of cells that causes the 
hard elevation or distinct papule; and it is simply an increase of the serum 
or lymph that elevates the cuticle and gives the appearance of a minute 
14 



210 ERUPTIVE FEVERS. 

vesicle on the apex of the papule. The two essential features of the pus- 
tule, namely, the papular or hardened base and the superimposed vesicle, 
having so far developed as to become plainly recognizable by the eye and 
the touch, both continue to increase in size, and pass through the stages 
of suppuration to maturity, and desiccation with cicatrization and a return 
to health. 

The vesicle commences like the pustule with a simple primary conges- 
tion of the capillaries of the papillae at a point in the skin, but without 
sufficient swelling of the epithelial cells to cause an elevated and hard 
base, while the serous exudation accumulates more rapidly, and separat- 
ing the cuticle from the cutis vera, presents at once a well formed vesicle 
filled with clear lymph, which subsequently becomes turbid but not 
purulent. The exanthem consists of the same primary congestion of the 
capillaries of the papillae of the corion, causing small red points, but with- 
out the enlargement of the epithelial cells of the pustule, and without 
sufficient exudation of serum or lymph to elevate the cuticle into a vesicle; 
consequently there is neither lymph nor pus visible during any part of 
their progress. Yet there is sufficient disturbarice of the connection 
between the cuticle and the vascular structure beneath, to cause a general 
exfoliation of the former at the commencement of convalescence. 

Whatever anatomical or structural changes may be found in the internal 
organs and structures, after death from any one of the eruptive fevers, 
will be the result of local inflammatory complications, and not in any 
degree characteristic of the general disease. Evidences of such local 
inflammatory complications are most frequently found in the mucous mem- 
brane of the respiratory passages, fauces and glands of the neck, kidneys, 
and parenchyma of the lungs. In the malignant cases, the blood is found 
in a condit : on closelv resembling the state of that fluid in the more severe 
cases of typhoid and typhus fevers. 

General Principles of Treatment. — If the views I have expressed con- 
cerning the etiology and general pathology of this group of diseases, are 
correct, they point to certain general principles of therapeutic manage- 
ment of much practical importance. 1st. The existence, in all these 
fevers, of an incubative stage, during which the minute quantity of the 
-contagium primarily imbibed, is presumed to be undergoing development 
or multiplication, suggests the question whether it is not possible to intro- 
duce into the blood enough of some efficient antiseptic to prevent such 
-multiplication, on the same principle of action that the presence of a cer- 
tain quantity of the sulphite of calcium in a cask of sweet cider or other 
fermentable liquid, prevents the fermenting process for an indefinite period 
of time. The antiseptics most likely to effect this object are the sulphites 
or hyposulphites of sodium, calcium, or magnesium; both on account 
of their known efficacy in preventing fermentation, and the safety of 
using them in sufficient doses to more freely impregnate the blood than 
can be done with most of the remedies belonging to the same class. The 
opportunities for testing the value of remedies in this stage are not 
frequent, as the physician is seldom consulted until active symptoms of 
disease have appeared. When it does happen that an individual comes 
under the care of a physician soon after fair exposure to one of these con- 
tagiums, the antiseptic is given freely through the whole incubative stage 
and no active symptoms of disease follow, there are left two points of 
uncertainty. First, the possibility that none of the contagium was 
imbibed at the time of exposure; and second, the insusceptibility of the 
individual to its action from other causes. Observation has long since 
shown that many children do not take the eruptive fevers of the exanthe- 



PRINCIPLES OF TREATMENT. 211 

matous variety when fully exposed to contact with them, while the very 
general practice of vaccination interferes with the results of other tests 
as applied to variola. In regard to the latter disease, three cases have 
come under my observation, affording apparently fair opportunities for 
testing the efficacy of the hyposulphite of sodium. The first of these 
occurred as early as 1850, and the last one was only one year since. All 
the three cases were nursing children, belonging to mothers who had 
direct care of unmodified small-pox, the babies remaining in the room and 
often lying on the bed with the sick through the whole course of the 
disease. Two of these were cases in which the father was attacked with the 
variola, and the other in which a daughter, eighteen years of age, had the 
disease. In each case, the mothers having nursing babies varying from 
four to eight months old, and never vaccinated, insisted on taking per- 
sonal care of the sick member of their families. As the little nurslings 
had been fully exposed before I saw them, I thought it better to comply 
with the wishes of their mothers. I immediately vaccinated each one as 
it came under my notice, and at the same time commenced giving it a 
solution of the hyposulphite of sodium in mint water, four times a day. The 
first vaccination did not take and it was repeated a second and a third 
time, but with no effect whatever. In the last case, one of the vaccina- 
tions was done by a medical officer sent from the city health office. The 
internal use of the hyposulphite of sodium was continued in each of these 
cases, not only during the ordinary period of incubation, but during the 
whole time they remained exposed to the respective cases of variola. 
Neither of these nursing children showed any signs of being affected by 
either the vaccine or the variola. 

Of course these three cases are not enough to justify me in stating any- 
thing more than the simple facts. 

After the incubative stage is passed and the virus or contagium is fully 
developed, as shown by the supervention of active febrile symptoms, there 
remains the same indication for the administration of such remedies as 
might be capable of neutralizing or destroying the noxious agent in the 
blood, and thereby rendering the further progress of the disease abortive. 
There is an important difference, however, between the prevention of the 
multiplication of an organic poison by the presence and catalytic action of 
some antiseptic remedy during the period of incbation, and the destruc- 
tion or neutralization of such poison after the quantity has already become 
sufficient to induce active morbid phenomena. To accomplish the lat- 
ter would require a much stronger impregnation of the blood with the 
antiseptic than is found practicable or compatible with the safety of the 
patient. It does not follow as a necessary inference, that, because safe 
doses of efficient antiseptics will not wholly neutralize the poison and 
render the disease abortive, they are of no value in the treatment of this 
class of contagious diseases. On the contrary, my own clinical experience 
has led me to think that when the administration of some of this class of 
remedies is commenced with the beginning of active symptoms, they 
may destroy so much of the poison as to materially lessen the severity of 
the case, as I shall state more fully when I come to speak of the treatment 
of each disease separately. 

2nd. Admitting that we have no reliable remedies for fulfilling the object 
just stated, the next rational indication is, to adopt such measures and 
give such remedies as will lessen the irritative action of those contagiums 
on the living structures and aid in effecting their elimination. When, at 
the commencement of active symptoms, the temperature rises rapidly with 
corresponding increase in the activity of respiration and circulation, fre- 



212 ERUPTIVE FEVERS. 

quent sponging of the surface with milk-warm water, and the internal use 
of such doses of veratrum viride or aconite in connection with spirits of ni- 
trous ether or liquor ammonii acetatis, as will moderate the force and fre- 
quency of the action of the heart and favor increased eliminations from the 
skin and kidneys, will lessen much the suffering- and restlessness of the pa- 
tient, and favorably modify the progress of the disease. You must keep con- 
stantly in mind the fact that these specific poisons have a natural tendency 
to accumulation in the cutaneous textures, and that their final elimination 
is chiefly through this surface, aided, perhaps, by the kidneys and the 
mucous membrane lining the first part of the respiratory passages. Con- 
sequently, all cathartics or other actively evacuant measures calculated to 
divert the circulation from the surface should be avoided during the pre- 
monitory fever, and only the milder laxatives used even after the eruptions 
are well established on the surface. 

3d. A third indication to be fulfilled in many of the cases, more espe- 
cially of variola and scarlatina, is to lessen the severity and mitigate the 
effects of the local inflammations which accompany them. As I have 
already explained to you, a large proportion of the deaths from variola 
result from the exhausting influence of the suppurative stage in the con- 
fluent cases; while a still larger proportion of the deaths from scarlatina are 
the result of the local inflammations and obstructions in the fauces, nostrils 
and glands of the neck. Two influences are needed in the management 
of these local affections; one calculated to lessen the amount of the local 
morbid actions while they are developing; the other to sustain the 
important functions, especially those of nutrition and repair, until con- 
valescence is established. 

If, as I have already suggested, the extent and severity of the local 
developments of disease in all the eruptive fevers depend on the quantity 
and activity of the specific contagium developed during the periods of incu- 
bation and primary fever; then so far as we can succeed in fulfilling the first 
and second indications I have pointed out, just so far will we be lessening 
the cause of the local affections, and thereby accomplishing the first part 
of this third indication. The second part is to be accomplished by secur- 
ing for the patient as good pure air as possible, the faithful use of such 
nourishment as is most easily converted into the nutrient elements of the 
blood, and the administration of such tonics as are best adapted to each 
case. 

4th. The last indication which should claim your attention is to guard 
your patients against the development of those important sequelae that are 
so well known as liable to occur during the convalescence from some of 
these fevers. If you study carefully the immediate causes of these several 
sequelae in connection with the hereditary and constitutional tendencies 
of each patient, you will often find it far easier, by timely attention and 
advice, to prevent their development, than to cure them after they are 
established. 

Having now considered the causes and general pathology of this third 
group of acute general diseases, together with the general indications and 
principles that should occupy our attention and guide us in their manage- 
ment, we are better prepared to enter directly upon the consideration of 
the symptoms or clinical history, diagnosis and special treatment of each 
member of the group. 



VAKIOLA. 213 



LECTUEE XXIV. 

Variola, Varioloid, and Vaccine— Their Symptoms, Diagnosis, Prognosis, Special Treatment, 
and Prophylaxis. 

GENTLEMEN: Although variola, or small-pox, has been deprived of 
much of that power to destroy human life, which it so frequently 
manifested before the discovery and practice of vaccination, yet it perpet- 
uates its existence, and is still a terror to all classes of the people. Its 
historv, causes, pathology, and anatomical characteristics were sufficiently 
explained in the preceding lecture, consequently I shall proceed directly to 
a description of its symptoms and progress as presented at the bed-side 
in the different stages of the disease. 

Symptoms. — After a riod of incubation varying from nine to fourteen 
days, the active symptoms of variola usually commence abruptly by a 
chill of varying degrees of severity, from mere chilliness to a severe chili 
of half an hour or more in duration; accompanied by severe pain in the 
loins; small, variable pulse; paleness of features; oppression or distress 
in the epigastrium, and sometimes vomiting. The cold stage soon gives 
place to increased heat; flushed face; a full and frequent pulse; acceler- 
ated respiration; heat and dryness of the skin; a white fur on the tongue; 
scanty and high-colored urine; very severe pain in the lumbar portion of 
the back; general aching of the head, back, and limbs, with more distress 
in the epigastrium and frequent efforts at vomiting. There is also much 
thirst and general restlessness, with more or less delirium in the severer 
class of cases. 

The symptoms of the initial stage, you perceive, are nearly the same 
as those which characterize the first stage of all active fevers. The tem- 
perature of the body increases rapidly, in many cases reaching from 40° 
"to 41° C. (104° to 106° F.) during the second and third days. There is 
usually but little variation or abatement of the febrile phenomena until a 
few hours before the commencement of visible eruptions upon the sur- 
face. There may be a slight remission or decrease of temperature each 
morning compared with the evening, and temporary appearances of moist- 
ure on the skin at irregular intervals. The first appearance of eruption is 
usually on the evening of the third or the morning of the fourth day after 
the initial chilliness, and consists, at first, of small red spots or points a 
little elevated and distinctly hard to the touch. In a few hours the little 
hard papule becomes more elevated and pointed, and a minute vesicle 
containing transparent lymph, or serum, may be seen at its apex. A few 
hours before the eruption becomes visible the patient begins to be less 
restless, and often falls asleep. The temperature, which had reached its 
climax about the middle of the third day, declines so rapidly as to reach 
the natural standard in all cases of moderate severity at the end of the 
fourth day, with a corresponding subsidence of all the other febrile symp- 
toms. In all such cases the patient remains quite free from active symp- 
toms for three days, or until the morning of the seventh day from the initial 
symptoms, when active inflammation in the pustules becomes apparent, 
and the temperature again rises to 38° or 39° C. (101° or 102.5° F.) with 
moderate restlessness, some thirst, and increase of frequency in the pulse, 



214 VARIOLA. 

but without the pains in the back and head that marked the first stage. 
This renewal of fever, caused by the inflammation attending the progress 
of the eruption, continues until the suppurative process is completed, 
which is from the tenth to the twelfth day after the commencement of 
active symptoms, when the temperature again falls rapidly to near the 
natural standard, and remains there until the process of desiccation is com- 
pleted and convalesence established. In the more severely confluent 
cases, during the primary fever there is a greater degree of distress in the 
epigastrium, with more persistent and severe vomiting; more frequent and 
smaller pulse, and more decided delirium; and when the eruption appears 
the temperature and other active symptoms subside more slowly, not 
reaching the natural standard of temperature until the end of the fifth day. 
In such severe cases the secondary fever is also renewed with greater in- 
tensity from the seventh to the eighth day, and usually continues until the 
eleventh or twelfth, when the suppurative stage is completed, and if the 
patient survives, the process of desiccation commences, attended by a rapid 
decline of all the febrile phenomena. In many of the more severely con- 
fluent cases, however, soon after the commencement of the secondary 
fever and while the suppurative process in the pustules of the eruption 
is progressing actively, the febrile symptoms present more of a typhoid 
character; the pulse becomes more frequent and feeble, varying from 120 
to 140 per minute; respiration unsteady, and sometimes sighing; lips and 
finger-nails leaden in hue; mind wandering, with subsultus and picking of 
bed-clothes; and finally involuntary discharges from the bowels, suppression 
or retention of urine; complete collapse, and death, most frequently be- 
tween the ninth and fourteenth days from the initial symptoms of the dis- 
ease. In some of these cases the fatal result is preceded by the appear- 
ance of petechial, or hemorrhagic spots in the skin, or by sudden and co- 
pious haemorrhage from the bowels, or by both. The petechial spots are 
most apt to occur on the upper part of the chest, sides of the neck, inside 
of the thighs, and on the legs. 

In the truly malignant grade of variola the commencement of the pri- 
mary fever is marked by a severe chill, followed by intense pyrexia, the 
temperature rising during the first forty-eight hours to 42° or 43° C. (108° 
or 110° F.); respirations hurried, irregular, and sighing; pulse very fre- 
quent, small, and feeble; face, neck, and upper part of the chest deeply 
suffused w.th a purplish redness; extreme sense of oppression across the 
chest, and distress in the epigastrium, with severe vomiting; more or less 
delirium; urinary secretion very scanty, and sometimes suppressed; and 
the bowels quiet, though sometimes loose. The eruption in some of these 
cases is preceded by the appearance on the evening of the second or 
morning of the third day of deep red spots upon the surface, sometimes in 
the form of an exanthematous rash, and in other cases more resembling 
large spots of roseola. These appearances usually disappear within twenty- 
four hours, and are replaced by the eruption specially characteristic of 
variola. The appearance of the latter is not accompanied by any decided 
diminution of the febrile symptoms, as in the non-malignant cases. On 
the contrary, all the symptoms I have just mentioned continue, with the 
addition of petechial spots on the surface, and haemorrhages from the nose, 
mouth, stomach, intestines, and in some cases from the kidneys, followed 
by low muttering delirium, involuntary discharges, and death between 
the fifth and seventh days. Having indicated the more prominent and 
essential symptoms accompanying the different grades and stages of va- 
riola, I must direct your attention to the successive changes that occur in 
the pustules, from tneir appearance on the third or fourth day to their 



SYMPTOMS. 215 

complete cicatrization between the fifteenth and twenty-first. As I have 
alreadv stated, the pustule appears first as an elevated, hard, and slightly 
reddened spot, or papule, easily recognized both by the eye and the touch. 
In from six to twelve hours later a minute vesicle is readily seen on the 
summit of the papule, or hard base. From this time (evening of the 
fourth day) to the seventh day of the disease, or fourth day of the erup- 
tion, both the hard base and the vesicle are steadily increasing in circum- 
ference, the latter umbilicated, or indented in the centre, and filled with 
a constantly increasing quantity of transparent serum, or lymph. During 
this time there is no discoloration of the skin between the pustules, and 
no general swelling; but at the beginning of the fourth day, after the first 
appearance of the eruption, an active inflammation attacks each pustule, 
causing an areola, or circle of redness around the base of each, with con- 
siderable tumefaction of the part, and a slightly turbid appearance of the 
serum in the vesicle. The inflammation and swelling increase for three 
or four days, during which time the vesicle becomes more distended, and 
finally, in most cases, loses its umbilicated appearance, while the fluid 
within has become fully transformed into pus. The stage of inflammation 
and suppuration having reached its climax on the tenth or eleventh day 
of the disease, or the seventh of the eruption, in one or two days more a 
dry, brownish spot appears at the point of previous umbilication in each 
pustule, which daily increases in size and becomes darker in color until it 
constitutes a dark-brown or black scab the full size of the pustule and 
closely imbedded in the surface. As this drying up or desiccating process 
goes on the febrile symptoms abate, the tumefaction gradually disappears, 
and cicatrization is rapidly progressing under the scabs. The latter proc- 
ess is usually completed in from five to seven days after the completion 
of the suppurative stage, when the scabs become rapidly detached, leav- 
ing the patient quite free and ready to be washed and clothed in about 
three weeks from the commencement of the disease. The degree of tume- 
faction of the surface during the stage of inflammation and suppuration 
will depend almost entirely on the number of the pustules. 

In the distinct, or discrete variety, the swelling of the face is rarely 
sufficient to close the eyelids, and the secondary fever is mild and of short 
duration. When the number of the pustules is sufficient to cause them 
to coalesce, or become confluent, however, the tumefaction is so great that 
the eyelids are completely closed, the natural lines and expression of the 
face obliterated, with considerable swelling of the whole surface. In the 
more severe cases of this variety, as the patient approaches the comple- 
tion of the suppurative stage, there is much cedematous infiltration into 
the subcutaneous areolar tissue indicated by pitting wherever pressure is 
made, and sometimes cellular abscesses form in several places and add to 
the discomfort of the patient. 

I have said nothing thus far concerning the pustules that come in the 
fauces and pharynx. They appear at the same time and pass through the 
same stages as those on the surface; but their presence causes, at first, 
simply a feeling of soreness, with an increased secretion of viscid saliva, 
or mucus, and when the inflammatory stage comes, the increased heat, 
soreness and swelling around them, with a more abundant secretion of 
mucus, is often sufficient to cause much pain and difficulty of swallowing 
and much annoyance from the necessity of frequent spitting or efforts to 
clear the throat. In confluent cases, accompanied by numerous pustules 
in the pharynx, it has sometimes happened that during the suppurative 
stage the tumefaction around the inflamed pustules has been increased by 
more or Jess oedema of the submucous tissue extending to the base of the 



21G VARIOLA. 

epiglottis, and sometimes so obstructing the breathing as to cause death 
from suffocation. One such case came under my own observation a few 
years since. In some of these cases the inflammation has extended tot he 
tongue, causing it to become so swollen as to protrude between the teeth and 
add much to the difficulty of deglutition. In rare instances one or more 
pustules appear on the conjunctiva of the eye, causing great irritation and 
sometimes sufficient ulceration to result in permanent impairment or loss 
of vision. From the commencement of the suppurative stage to the es- 
tablishment of convalescence there is a peculiar and unpleasant odor 
emanating from the body of the sick, which in the more severely confluent 
and malignant cases is so strong as to impregnate the whole atmosphere 
of the room and require constant attention to disinfection and ventilation. 

Diagnosis. — During the stage of primary fever, before any appearance 
of an eruption, there are no symptoms so peculiar or distinctive, as to en- 
able the physician to make a positive diagnosis between small-pox and at- 
tacks of other active grades of fever. 

The abruptness of the attack from a previous state of good health, the 
rapid rise of temperature, the general redness of the surface, and espe- 
cially the severe pains in the loins, should be sufficient to excite the sus- 
picions of the practitioner. And if these symptoms have supervened in 
from nine to fourteen days after a known exposure to the contagion of va- 
riola, it would change the suspicion into an approach to certainty. 

It is not, however, until the appearance of the eruption that the diag- 
nosis can be made positive. The appearance on the evening of the third 
or morning of the fourth day, upon the face, neck and upper part of the 
chest, of a greater or less number of hard elevated points, with minute 
vesicles forming on the apex of each, and generally accompanied by a 
marked subsidence of the febrile symptoms, is so distinctive as to leave 
no room for further uncertainty. The elevation and hardness of the pimples 
at once distinguishes them from all the exanthematous varieties of fever. 
The smallness of the vesicle on its first appearance, and its position on a hard 
and elevated base, equally distinguishes it from the much larger vesicle, 
without any hard base, that characterizes varicella. Each subsequent 
day after the first, only serves to make the distinctive features more plain 
by the enlargement, flattening and umbilication of the vesicles. 

Prognosis. — In all cases of distinct or discrete variola, the prognosis is 
favorable. In all cases presenting only a moderate degree of confluence 
of the eruption, such as confluent patches of limited extent on the face 
and back of the hands, the tendency is to recovery. But in the more ex- 
tensively confluent cases, and those presenting special symptoms of ma- 
lignancy, there is a strong tendency to fatal results ; and no method of 
treatment has been devised capable of preventing a high ratio of mortal- 
ity. The general ratio of deaths to the whole number of cases of unmod- 
ified small-pox, varies from one in three to one in ten. It is more fatal in 
early childhood and in old age, than in the middle period of life. A large 
percentage of the deaths are caused by such complications as pneumonia, 
oedema of the glottis, endocarditis and uremia from active renal con- 
gestion. - 

Special Treatment. — In speaking of the general principles which 
should guide us, and the objects to be accomplished in the treatment of 
the whole class of eruptive fevers yesterday, I stated that it was desirable, 
in the early stage, to cause the destruction or elimination of as much of 
the specific cause as possible ; to palliate its direct irritative action on 
the structures of the body ; and in the middle and later stages, to sus- 
tain the nutrition and strength of the patient. Among the antiseptics 



TREATMENT. 217 

supposed to be capable of neutralizing or destroying animal poisons or 
specific contagiums, I have found none capable of being used safely in 
sufficient quantity to make an impression, except the hyposulphites of 
sodium and calcium. During the last twenty years I have given nearly all 
the cases of unmodified variola, coming under my care in the early stage, 
from 0.6(5 to 1.00 gram. (gr. x to xv) of the hyposulphite of sodium, dis- 
solved in mint water, every four hours ; and through the stage of erup- 
tion in the confluent cases, it has been continued from three to four times a 
day. In the discrete variety of cases, its continuance after the establish- 
ment of the eruption on the surface, is not necessary. Neither is it nec- 
essary to give patients laboring under this mild variety of the disease any 
active remedies after the primary fever has disappeared. To keep their 
rooms well ventilated, cleanly, and at a comfortable temperature ; to give 
them light, plain food; an occasional laxative or enema if the bowels do not 
move without, and a moderate dose of the compound powder of opium 
and ipecacuanha at night during the suppurative stage, constitutes all the 
treatment necessary, unless some important local complication occurs. In 
cases of greater severity, however, accompanied, during the primary fe- 
ver by great epigastric distress and frequent vomiting, I give six centi- 
grams (gr. i) of calomel with three decigrams (gr. v) of white sugar, 
every two or three hours, and half way between the powders, four cubic 
centimeters (13, 3i ) or & teaspoon ful of the carbolic acid mixture (see for- 
mula on page 138) until the vomiting ceases and the eruption begins to 
appear upon the surface. During the same time I apply sinapisms to the 
epigastrium and along the lower dorsal and lumbar portions of the spine ; 
and while the skin is hot and dry have it frequently sponged over with 
milk- warm water, and if there is delirium I keep the head covered with cloths 
wet in water of the same temperature. In these more severe cases, if 
the hyposulphite of sodium is rejected by the stomach, it can be given 
by enema. When the eruption has appeared, accompanied by the usual 
abatement of fever, if the bowels have not moved during the two preced- 
ing days, I give a saline laxative sufficient to evacuate the bowels mildly, 
and discontinue all the preceding remedies, except the solution of the hypo- 
sulphite, which I continue at intervals of once in six hours, and secure rest 
at night by a single dose of 0.4 or 0.5 grams (gr. vi or viii) of the com- 
7»ound powder of opium and ipecacuanha given at bed-time. If pustules 
appear in the fauces and pharynx, mucilaginous and slightly astringent 
gargles are used frequently to allay the heat and help to dislodge the ex- 
cess of mucus. Milk and meat broths are given in quantities sufficient to 
sustain a good decree G f nutrition. When the stage of inflammation and 
suppuration commences in the eruption, and secondary fever with more 
weakness supervenes, I discontinue the hyposulphite, and give in its place 
moderate doses of the tincture of the chloride of iron and sulphate of 
quinia every four hours ; and as this stage progresses toward comple- 
tion, if the pulse becomes decidedly soft and weak, respiration occasion- 
ally sighing, and the mind either dull or wandering, I give four cubic 
centimeters, or a teaspoonful of the following mixture, between the doses 
of the quinine and iron: — 

Jfr Ammonii Carbonatis 
Aquae Camphoras 
Syrupus Simplicis 

Mix. Put each dose with an additional tablespoonful of water when it 
is given to the patient. 



10 grams 


3iiss 


110 c. c. 


giiiss 


15 c. c. 


?ss 



218 VARIOLA. 

Close attention should also be given at the same time to the faithful ad- 
ministration of such nourishment as milk, milk and flour gruel, and meat 
broths, with small and frequent doses of pretty strong tea or coffee, to 
maintain nerve sensibility. If, as sometimes happens, the bowels at this 
stage become loose, giving rise to thin discharges, the emulsion of tur- 
pentine and tincture of opium should be promptly given in such doses 
and at such intervals as is necessary to hold them in check.* If petechial or 
haemorrhagic spots appear on the surface, or the intestinal discharges be- 
come bloody, suitable doses of strychnine and nitric acid may be given in- 
stead of the quinine, between the doses of the emulsion. If free intestinal 
haemorrhage occurs, it is proper to use astringent enemas, and for imme- 
diate effect in controlling the flow of blood, from sixty to one hundred 
and twenty milligrams (gr. i to ii) of persulphate of iron in solution 
with water, may be given every hour until the haemorrhage is checked, 
when the emulsion and other remedies should be resumed, as I have just 
stated. 

Malignant Cases. — The genuinely malignant cases of this disease have 
generally progressed to a fatal result, regardless of the influence of any 
remedies hitnerto proposed. Yet it is the duty of the physician to make 
an effort to relieve his patient, however small may be the chance of suc- 
cess ; and the effort should be founded on some rational indications af- 
forded by the pathological conditions of the patient. If it be true that 
the special symptoms indicating malignancy depend upon the continued 
action of the poison on the blood, either through excess of its quantity or its 
failure to be fully lodged in the cutaneous tissue at the commencement of 
the eruptive stage, then the first and most important indication is, to neu- 
tralize or in some way destroy this excess of virus and thereby render the 
blood again capable of making its natural impression on the properties 
of the tissues and the sensibility of the vaso-motor nervous system. I 
know of no agents better calculated to fulfill this indication, than a com- 
bination of the hyposulphite of sodium and carbolic acid, given in such 
doses and at such intervals as will most rapidly impregnate the blood as fully 
as is compatible with the safety of the patient. In two cases of a decidedly 
malignant type occurring in the practice of the late Dr. F. H. Davis, the 
following formula was given with decided benefit, apparently modifying 
the condition of the patients to such a degree that both finally recovered. 
In another case to which I was called during the past year, presenting ex- 
tensive petechial and haemorrhagic symptoms, the patient died within for- 
ty-eight hours after my first visit, without showing any apparent effect of 
remedies. The formula I have used is as follows: 



Sodii Hyposulphitis 


25.0 grams 


3vj 


Acidi Carbolici 


0.6 " 


grs. x 


Aquae Menthae, 


130.0 c. c. 


Ijv 



Mix. Shake the vial and give four cubic centimeters, or one tea- 
spoonful, in a tablespoonful of additional water every one or two hours 
until some effect is obtained, and then lengthen the interval between 
the doses. During the same time the patient may be supported by the 
taking of carbonate of ammonia and camphor, and the use of nutritive 
enemas. In all other respects these cases may be treated in the same 
manner as the more severe variety of the confluent form. 

* See formula on page 116. 



SYMPTOMS. 219 



VARIOLOID. 



Soon after the introduction of vaccination as a preventive of variola, 
it was ascertained that a small proportion of those who had taken the vac- 
cine, at some subsequent period when exposed to the contagion of vari- 
ola, took the disease, but always had it in a modified form, being shorter in 
duration and in all respects less severe. To distinguish these cases from 
those of unmodified variola, they were called varioloid. 

You will understand, therefore, that cases of varioloid are simply cases 
of small-pox, rendered milder and less dangerous to the patient on ac- 
count of the partial protection afforded by a previous vaccination. All 
these cases are caused by the true variolous poison or virus; and no matter 
how mild they may have been rendered by the influence of the previous 
vaccination, they are all capable of communicating the true unmodified 
small-pox to any unprotected persons with whom they may come in contact. 

Symptoms. — The period of incubation is the same as in ordinary vari- 
ola; and all the symptoms accompanying the onset of active phenomena 
and the three or four days of primary fever, are the same as in the corre- 
sponding stage of mild or discrete small-pox. The eruption also appears 
during the night of the third or morning of the fourth day, and presents 
the same hard, papular elevations, with minute vesicles at the apex, and is 
accompanied by an entire subsidence of the general febrile symptoms. 
The amount of the eruption varies very much in differeut cases, from no 
more than five or six pustules in some, to a number fully equal to those ac- 
companying the unmodified discrete variety of the variola. The pustules, 
whether many or few, increase in size, and the vesicles become first flat- 
tened, slightly umbilicated, and filled with clear lymph; then are attacked 
with inflammation and suppuration, but less severely, and accompanied by 
less tumefaction and less secondary fever than in the mildest cases of the 
unmodified disease. Consequently the suppurative stage is shorter, many 
of the vesicles failing to fill up with matter, and the whole drying up 
and commencing to desquamate in from seven to nine days after their ap- 
pearance on the surface. From the mildness of many of these cases, and 
the sparseness of the eruption, some of the patients, not suspecting the 
nature of their sickness, get up as soon as the primary fever is passed, 
and go out to their usual places of business, and thereby do more to spread 
the disease than any other class of subjects. 

I have known several cases, in which individuals after suffering severe 
pains in the loins and back with some general fever for three or four days, 
were altogether relieved on the appearance of a few pimples on the face and 
neck, but not liking the appearance of the pimples, have gone directly to 
some one of the public dispensaries, and in two instances to a physician's 
office, and sat in the midst of other patients in the waiting-room, until 
their time came for examination. It is by such means that many individ- 
uals not fully protected, come in contact with the contagium of the disease, 
and take it without the slightest knowledge, on their part, of the time or 
place of their exposure. It is therefore of great importance that all cases 
of varioloid, however slight, should be recognized early and subjected to 
the same complete isolation, as in the more severe cases of small-pox. 

Diagnosis. — The sudden development of unusual pains in the back and 
loins with some general fever, continuing three or four days, and disap- 
pearing on the appearance of distinct hard papules with minute vesicles 
on their apex, on any part of the cutaneous surface, but more especially 
on some parts of the face, neck, and upper part of the chest, constitute 
a group of symptoms following each other in such order as to make them 



220 VACCINIA. 

reliably diagnostic of variola or varioloid, even though the pustules did 
not exceed half a dozen n number. 

Prognosis. — The prognosis in varioloid is favorable, cases very rarely 
terminating fatally, unless from some important complication, as pneumo- 
nia, dysentery, etc. Indeed, the essential idea indicated by the word va- 
rioloid, is a modified or less severe form of variola. And a case which is so 
little influenced by the previous vaccination that it proceeds to a fatal result, 
from its own gravity would certainly be more properly designated as va- 
riola than as varioloid. 

Treatment. — The treatment of cases of varioloid does not differ in any 
respect from that required by mild cases of variola. The same care 
should be exercised to isolate the patient ; to preserve strict cleanliness 
and good ventilation of the sick room ; to adhere to a plain, simple diet ; 
and use only such medicines as may be required to regulate the bowels 
and more important secretions, and to remove any important complica- 
tions that may arise. 

Prophylaxis. — Aside from strict isolation of the sick and the preserva- 
tion of good sanitary regulations, the principal measure relied upon for 
preventing the occurrence of both variola and varioloid, or limiting their 
spread in any community, is vaccination. 

VACCINIA. 

By vaccination is meant the introduction through the skin, of a 
virus originally obtained from a peculiar sore or pustule that is oc- 
casionally found on the udder of cows ; and which not only makes a 
specific local pustule at the point of introduction, but so changes the con- 
dition of the whole system as to render it thereafter incapable of being- 
influenced by the contagium of variola. From what source the cow be- 
came affected with the vaccine disease is not known. Some writers have 
claimed that it was from the disease called Grease on the ankles of 
horses, and that it was communicated to the udder of the cow by the hands 
of milkmen who were at the same time handling the horses affected with 
that disease. Others have claimed that the pustules on the cow were 
simply the result of the contagium of variola, and consequently that the 
virus of variola and vaccine are identical, the latter having been ren- 
dered milder in its properties and effects by its passage through the sys- 
tem of the cow. Though much has been written on this subject, and 
many experiments performed to prove or disprove this and that theory, 
the real origin of the vaccine disease in the cow has not been ascertained 
with any reasonable degree of certainty. The discovery of the true cow- 
pox and the application of the virus found in the pustules on the udder 
of the cow to the vaccination of man for destroying his susceptibility to 
small-pox, was made by Dr. Edward Jenner, a surgeon who commenced 
practice in Berkeley, Gloucestershire, England, in 1772. His attention was 
arrested by the remark of a milk-maid, to the effect that she could not 
take the small-pox because she had previously had a sore on her hand 
contracted from a sore on the udder of a cow while milking. This led 
him to a thorough investigation of the subject, by which he identified 
the true cow-pox pustule and such proofs of its power to protect those in- 
dividuals from small-pox who had been accidentally inoculated with the 
virus from it, that he felt justified in trying it, first, on a member of his 
own family, and subsequently on others. He early communicated freely 
with the celebrated John Hunter of London who encouraged him to con- 
tinue his experiments. This he did, and published the full results in 



HISTORY. 221 

IT.iS. The same year Mr. Cline commenced vaccinating in London with 
the matter obtained from Dr. Jenner. And though the new practice ex- 
cited much apprehension and some intemperate opposition both in and 
out of the profession, yet so rapidly were its benefits demonstrated by act- 
ual experience, that in two short years, it received the unequivocal en- 
dorsement of the best part of the profession in London and other parts 
of England. 

The next year after Mr. Cline commenced vaccinating in London, the 
practice was initiated in Boston by Dr. Benjamin Waterhouse, the first 
professor of practical medicine in the medical school of Harvard Univer- 
sitv. The new practice met here the same opposition and prejudices as in 
London, but both were soon overwhelmed by the rapidly accumulated 
proofs of its safety and efficacy as a preventive of variola. Such was the 
origin of vaccination, which in less than one century has bestowed upon 
our race an amount of benefit that cannot be properly expressed in either 
words or figures. I will not trespass upon your time, however, to enter 
upon any consideration of the history of vaccination since the days of 
Dr. Jenner, but assuming that it affords a safe and reliable mode of pre- 
venting one of the most destructive and loathsome diseases in the list 
of acute affections, I will call your attention at once to the following ques- 
tions of great practical importance : First, what are the characteristics 
of the genuine vaccine disease as developed in the human subject by vac- 
cination? Second, what is the best method of procuring and preserving 
reliable vaccine virus for use inordinary practice? Third, in what man- 
ner and at what times should vaccination be practiced in order to insure 
the most reliable protection from variola? 

In answer to the first question, I will say that when the vaccine matter 
is introduced into, or placed in contact with the cutis vera, at some point 
on the cutaneous surface, there is no appearance of active influence until 
some time between the beginning of the fourth and sixth days ; when 
there appears at the point of insertion a slightly red and hard elevation, 
which in twenty-four hours more has increased in circumference and de- 
veloped a slightly flattened vesicle on its surface. Both the hard base 
and the vesicle continue to increase in size (the latter becoming indented 
or umbilicated in the centre), for about four days after their first appear- 
ance, during which time the vesicle is filled with transparent lymph 
contained in several distinct compartments, as in the vesicles of variola. 
At the end of the fourth day of progress, or the eighth after vaccina- 
tion, a red areola appears around the base of the sore, accompanied by 
some swelling, heat and slight pains, with a slightly turbid appearance of 
the lymph. 

The redness and tumefaction increase for three days more, accompa- 
nied by slight general fever; sometimes pains in the head, back and limbs ; 
occasionally swelling of the glands in the axilla ; and always a more 
complete conversion of the contents of the vesicle into a thick straw-col- 
ored pus. At the end of this time, about the eleventh day after the vac- 
cination, the pustule or pock has reached its full maturity; a dark-brown 
spot now appears in the center of the sore at the point of umbilication ; 
the redness and swelling begin to abate ; the general feverishness disap- 
pears ; and by the fifteenth day, a dark-brown thick scab has taken the 
place of the vesicle. Cicatrization goes on under this scab, and somewhere 
between the twenty-first and the twenty-fifth days it is completed and 
the dry scab falls off, leaving a concave cicatrix with from one to four or 
five distinct depressions, or pits as they are generally called. The pres- 
ence of these pits or indentations in the cicatrix is permanent, and ever 



222 VACCINIA. 

afterwards affords proof that the vaccine sore was genuine. Th? forma 
tion of these indentations in the scar resulting from a true vaccine sore, 
maybe prevented, however, by unusually deep or extensive ulceration 
during the suppurative stage of the sore. Consequently their absence 
from the scar cannot be regarded as conclusive evidence that the vaccina- 
tion was spurious. You will see by the description I have given, that a 
true vaccine sore or pustule develops in the same manner and passes 
through the same stages as the pustule of variola, differing chiefly in the 
attainment of a much larger size than any single pustule of the latter. 

On the contrary, the sores produced by the use of spurious vaccine matter, 
commence sooner after its introduction, run their course more rapidly to 
the suppurative stage, seldom present any distinct umbilication, and 
either dry up early and leave a smooth cicatrix, or extend the suppurative 
stage into a large spreading ulcer' with an abundant formation of thin 
pus, and no disposition to cicatrize. Sometimes, though rarely, the prog- 
ress of true vaccination is accompanied by a scattering eruption of small 
vaccine pustules on different parts of the surface. These pass through 
the same stages and disappear with the parent sore. 

Methods of procuring and preserving the vaccine matter for use are 
numerous, and each has its advocates. Until a recent date the disease 
was propagated exclusively by taking the matter from the vaccine pustule 
on the arm of one individual to vaccinate others, thereby extending it 
from individual to individual by what is now called humanized virus. 

Many preferred to use the transparent lymph obtained from the va *- 
cine vesicle just before the commencement of the suppurative stage. 
By pricking the vesicle at this stage the drops of lymph that ooze out 
may be received on quill or ivory points, allowed to dry on, the same en- 
veloped in a little cotton, and kept in a dry, well-stopped vial until needed 
for use. The leading objection to this method is, that the virus is so much 
exposed to the air that it will retain its activity but a brief period of time. 
Another method consists in receiving the lymph, at the same stage of the 
vaccine vesicle, into capillary glass tubes, hermetically sealing them, until 
needed for use. By this method the virus maybe preserved active for 
a long period of time, provided the tubes remain unbroken, and are not 
exposed to too great extremes of temperature. In this country perhaps the 
larger number of practitioners have preferred to let a genuine vaccine 
pustule complete its course unbroken, until cicatrization is complete and 
the dry scab is loosened and ready to fall off. The dry scab is then taken, 
allowed a few hours for further drying, and preserved for use in one of the 
following modes: First, the dry scab maybe immediately wrapped in 
tin foil and inclosed in the center of a ball of white wax. This excludes 
nearly all the air and is capable of preserving the active properties of the 
scab several w T eeks. Second, the dry scab is comminuted or broken up 
and mixed with pure glycerine, which is capable of dissolving the active 
principle of the scab, and if the vial is kept well stopped, and secluded 
from the light, preserving it active for an indefinite length of time. One 
fresh ordinary sized scab is capable of impregnating from one to two 
drams of glycerine. Third, a fully matured and dry scab may be cut in- 
to four pieces, each piece closely enveloped in foil, and one of them 
placed in the center of a ball of white wax for immediate use, while each 
of the other three should be placed in glass tubes hermetically sealed at 
one end, the air mostly expelled by a moderate heat and the other end 
sealed quickly, and kept secluded from light or high heat until needed 
for use. When needed, the tube is broken and the inclosed piece of scab 
transferred to the ball of wax as already mentioned. This can be open- 



BOVINE VIRUS. 223 

cd, a part of the seal) shaved off on a clean piece of glass, and the rest 
returned to the wax enclosure, as often as a person is presented for vacci- 
nation, until it is all used, or by time and repeated exposure to the air, 
its active properties have been lost. If the general practitioner will see 
that every baby born within the circle of his practice, is properly vacci- 
nated between the ages of four and eighteen months, he can easily select 
scabs enough from the arms of strictly healthy children, to keep his sup- 
ply good, if prepared in the manner last indicated. It is the method that 
1 have practiced for more than thirty years w T ith almost uniform success, 
and without any bad results. The scab should be allowed to fully mature 
on the arm, and should be selected only from strictly healthy children 
undergoing a primary vaccination. Until 1866, the humanized virus, ob- 
tained and preserved in some one of the ways just mentioned, was solely 
relied on by the profession for vaccination. At that date a case of spon- 
taneous vaccinia or cow-pox, was discovered at Beaugency, in France, 
and the virus obtained from that case was carefully multiplied and prop- 
agated by successive vaccinations from one heifer to another, under the 
direction of M. Depaul,of the French Academy of Medicine. The work 
was sanctioned by the Academy and aided by the French government. 

The fresh virus thus obtained was used for human vaccinations, under 
the name of bovine or non-humanized virus. 

In 1870, virus from this stock was obtained by Dr. Henry A. Martin, 
of Boston, who immediately commenced, and still continues, its careful 
propagation from heifer to heifer, and from whose establishment near 
Boston, large quantities of the virus have been furnished to the profession 
in all parts of the country, and extensively used as a substitute for the 
humanized virus previously so universally depended upon. 

The demand for the bovine virus increased so rapidly that several other 
establishments for its propagation have been started in different parts of 
the country, the virus from which appears at present, to be wholly super- 
seding that obtained from the human subject. The impression has be- 
come quite general, that the protective influence of the bovine is superior 
to that of the humanized virus. I am constrained to say, however, that 
I deem the evidence on this point by no means conclusive. That the 
fresh bovine virus furnished from the propagating establishments gener- 
ally produces a larger vaccine sore, more intense local inflammation, and 
more specimens of large, open ulcers, slow to heal, I think is fully proved 
by the experience of the profession in this city. I have certainly seen a 
larger number of such results in the last two years, during which the bo- 
vine virus has been so extensively used in this city, than during all the 
years of my professional life previously. This, however, is no proof that 
the protective influence is greater, or more permanent. 

Indeed, if you remember that it is only eleven years since Dr. Martin 
introduced and commenced the propagation of the Beaugency stock of 
virus in this country, you will readily perceive that the time since the first 
vaccinations with it, has not been sufficient to afford an opportunity to 
make any deductions concerning the comparative durability of its effects. 
I can find nothing in the known laws governing the development of or- 
ganic matter, which would explain why a particular specific virus should 
deteriorate any more by transmission from one child to another, than from 
one heifer to another. And as a matter of clinical experience, I must 
say that I have discovered no difference whatever between the degree of 
protection afforded by a genuine vaccination with humanized virus now, 
and fifty years ago. During that whole period I have not known a single 
instance where a successful vaccination with matter taken from a genuine 



224 VACCINIA. 

vaccine pustule resulting from a primary vaccination, has not afforded full 
protection for at least a term of ten or fifteen years. I say matter from 
a pustule resulting from a primary vaccination, because I am well satis- 
fied that all the deterioration which has taken place in the humanized 
virus since the days of Jenner, has resulted from the use of lymph or 
scabs taken from secondary vaccinations, or imperfect vaccine sores, and 
which may be regarded as bearing the same relation to the primary vac- 
cination that varioloid does to variola. 

From a full consideration of this important subject, I am satisfied that 
the safest and best course for every practitioner to pursue is, to procure a 
supply of fresh bovine virus, select a healthy child between two and five 
years of age, never before vaccinated, introduce the fresh virus at the 
proper place on the arm, and if a good characteristic vaccine sore is pro- 
duced, let it run its complete course undisturbed, and when the dry scab 
begins to loosen, take it off, leave it exposed to the air a few hours until 
more perfectly dry; then take one-quarter of it for immediate use, en- 
closed in foil and wax, as already described, and put each of the other 
quarters into as many glass tubes, hermetically sealed for longer preserva- 
tion as reserve stock. 

Let him make it a rule of professional life to see that every child born 
within the circle of his practice, is vaccinated with the matter he has in 
store, and as often as he finds a healthy child from healthy parents, save 
the vaccine scab and treat it as just described, and he will not only be 
able to keep his stock good for five or ten years at a time, but he will 
have the satisfaction of affording the highest degree of protection to those 
who depend upon him as a medical adviser, with the smallest number of 
casualties or bad results. If by some chance his stock fails, immediately 
procure a fresh supply and commence the work of independent propaga- 
tion anew. While I have no hesitation in recommending this as the safest 
and most reliable course for every general practitioner to pursue, the 
demands of public institutions and municipal health boards, will make 
the continuance of a few well-conducted establishments for propagating 
the bovine virus not only a convenience, but a public necessity, even if 
they should require governmental aid and regulation. And this brings 
me to the third and last question, namely, in what manner and at what 
times should vaccination be practiced? I know of no simpler or better 
mode of practicing vaccination than to very lightly scarify one or more 
places on the arm near the insertion of the deltoid muscle, on which the 
vaccine matter should be placed in a liquid or moist condition. The best 
instrument for the purpose is a sharp pointed knife or lancet, and the 
scarifications should be so directed as to scrape off the cuticle, carrying 
the incisions just deep enough to make the blood visible without causing 
it to start out in drops. 

If you have the virus on quill or ivory points, these should be 
moistened with clean water when you commence to scarify, and then 
rubbed freely into the scarified place. If you use the dry scab, a small 
part of this should be shaved off on a clean piece of glass or earthen, and 
rubbed up with just water enough to moisten and dissolve it, then taken 
up on the point of the knife and placed on the scarified spot, and rubbed 
or pricked into it with due care. After the matter is introduced, it should 
be left uncovered until entirely dry, and then covered only by the ordin- 
ary clothing. 

Some statistics have been published which seem to indicate that the de- 
gree and durability of the protection from vaccination depends in some 
measure on the number of vaccine sores made on the arm. Consequently 



VARICELLA. 225 

it has become a common practice to scarify two, three and sometimes four 
places on the arm, thereby producing a corresponding number of sores. 

So far as these statistics have come under my observation, they are too 
meagre in amount, and unaccompanied by certain collateral observations 
which are essential to give them value. For instance, each case should 
be accompanied by the age at which the vaccination took place, and the 
number of years intervening between the latter and the time of taking the 
variola. In vaccinating infants under one year, I would make but one 
sore. In older children and adults, it may be well to make two points of 
insertion. In regard to the times at which vaccination should be practiced, 
all agree that every child living, and in ordinary health, should be vac- 
cinated, if possible, between the ages of six and eighteen months. The 
operation should be considered of sufficient importance to receive the care- 
ful attention of the physician, and it would be better if its efficiency should 
be tested by a second vaccination, one or tw T o months after the first. 

Having thus secured a genuine and efficient vaccination in infancy, 
there is no need of repeating it until the child has arrived at maturity of 
growth, between eighteen and twenty-five years of age. Then the vac- 
cination should be repeated, and tested with the same care as at the first. I 
think thorough vaccinations with virus of known active qualities, at the 
two periods named, is sufficient for the whole life-time, except in those in- 
dividuals, who, after the second vaccination, have suffered some attack of 
disease, whereby their tissues become so wasted, that the repair is almost 
equal to a new growth, or have made a radical and permanent change of 
climate. 

Such exceptional cases should be vaccinated a third time, after the 
changes mentioned have taken place. While these are all the vaccinations 
I deem necessary for the safety of the individuals and of the commu- 
nities, provided they are done with proper care, and with virus known to be 
genuine and active, yet every physician is justified in vaccinating his pa- 
trons as much oftener as they desire, provided their fears can not be allayed 
without so doing. 



LECTUEE XXV. 

Varicella— Its Symptoms. Diagnosis and Treatment. Sudamrna— Scarlatina— Its History, Symp- 
toms and diagnosis. 

GENTLEMEN: I shall first occupy your attention with the consideration 
of varicella or chicken-pox. The name, varicella, literally means little 
small-pox, and was adopted in the early period of medical history, when 
the disease was very generally regarded as a modified form of the variola. 
That it is entirely distinct and unconnected with small-pox, however, 
is proved by the following facts : The period of incubation is longer ; the 
primary fever before the eruption is shorter ; the eruption is purely vesic- 
ular, instead of pustular, and completes its course in much less time, and 
one attack of varicella affords no protection against subsequent attacks of 
variola, neither does one attack of variola or of vaccinia, afford any protec- 
tion against varicella. 
15 



226 VARICELLA. 

It prevails chiefly in epidemic form, and almost exclusively among chil- 
dren and youth, though it sometimes occurs during adult life. 

It is contagious or communicable from one child to another, and rarelv 
attacks the same patient more than once. Most of the attempts to prop- 
agate the disease by inoculation have failed. Its period of incubation is 
stated variously by different writers. By some it is placed from twelve to 
seventeen days (Flint); by others as short as from four to five days 
(Hartshorne). The primary or premonitory fever is only one day, and is 
so slight as not to attract any attention in many cases until the eruption 
begins to appear. In other cases it is sufficient to cause two or three de- 
grees elevation of temperature; slight increase in the frequency of the 
pulse, with aching pains in the head, back and limbs, and some restless- 
ness. The eruption begins on the second day, and is often the first thing 
to attract the attention of the patient or of those about him. It generally 
appears first on the body, and quickly extends to the neck and scalp, the 
vesicles being scattered or widely separated from each other, and new 
ones continue to appear for two or three days, during which time the gen- 
eral febrile symptoms disappear. The vesicles constituting the erup- 
tion vary in size from that of a pin's head to the circumference of a large 
pea. They are preceded for a few hours by a simple red or rose-colored 
spot on the surface, without hardness or elevation, and soon give place to 
the vesicle, which attains its full size in a single day, is filled with trans- 
iparent lymph, and by the third day has commenced to shrivel or dry up, 
without any decided areola of redness around it, and without suppuration 
or tumefaction of the surface. The scab formed is tfrn, light-colored, 
and falls off, leaving no permanent cicatrix or indentation. The whole 
course of the disease is usually completed in from seven to nine days. 
The disease is so brief and mild in its character as to require little or 
no professional attention. 

Diagnosis. — The chief interest attached to it rolates to a proper diag- 
nosis between it and the other eruptive fevers. The only one of these 
with which it could be confounded without great carelessness, is varioloid. 
But if you remember that the primary fever in both variola and varioloid 
is three days, and is of considerable severity, and that the eruption is in 
both always papular and elevated, with only a minute vesicle on the point 
-of the papule, while in varicella the primary fever is so slight as to at- 
tract but little attention; and that the eruption appears on the first or sec- 
ond day, and is a simple, plain vesicle filled with transparent lymph, with- 
out any hard base, without umbilication or indentation in the center; and 
that it begins to shrivel or dry up without inflammation in three days; 
you can hardly fail to distinguish the varicella from the varioloid and vari- 
ola. Still greater is the contrast between the fair-sized, prominent ves- 
icle of varicella, and the small red points constituting the eruptions of 
scarlatina and measles. 

Treatment. — A very large majority of the cases of varicella need only 
hygienic management; rest, a mild, simple diet, and the maintenance of 
a comfortable temperature, with proper ventilation, and cleanliness, are 
;all that is necessary. In a very few of the more severe cases, it may be 
.better to act gently on the secretions and promote regular intestinal evac- 
uations, by giving the patients moderate doses of the bi-tartrate of potas- 
sium dissolved in cold water, with a little sugar. If four grams (3i) of 
the bi-tartrate are dissolved in an ordinary sized tumbler, full of cold 
water, and a little sugar added to render it palatable, from four to sixteen 
cubic centimeters may be taken every three hours during the day, the 
dose being varied in accordance with the age of the patient. If at any 



SUDAMINA AND SCARLATINA. 227 

time the bowels become too loose, a moderate dose of the compound 
powder of opium and ipecacuanha, may be given at night, and it will both 
correct the looseness and promote sleep. No important sequelae follow 
attacks of varicella. 

SUDAMINA. 

There is no distinct form of febrile disease called sudamina; but the 
name is applied to an eruption of very small, white, or silver-colored ves- 
icles that sometimes appear on the skin during the progress of many 
febrile diseases; more especially those cases which are characterized by 
copious and protracted sweating. Their appearance is generally limited 
to the trunk of the body and lower part of the neck. The vesicles are 
usually not more than one line in diameter, tilled with perfectly transpar- 
ent fluid, and pretty closely aggregated, but they are so small and color- 
less that their presence is easily overlooked. The contents of the vesicles 
give an acid reaction, and contain chlorides. They give no uneasiness to 
the patient, and usually shrivel up and disappear in from three to five 
days, with roughness from desquamation of the cuticle. They are most 
frequently seen in those cases of acute rheumatic fever, accompanied by 
continuous sweating, and in such cases of typhoid and typhus as present 
the same symptom for one or more days at a time. Indeed, the eruption 
appears to be caused by excessive perspiration, especially of an acrid or 
sour reaction, and the fluid in the vesicles appears like retained perspira- 
tion. No treatment is needed for this form of eruption. 

SCARLATINA. 

I come now to consider the exanthematous group of eruptive fevers. 
The most important of these is scarlatina, or scarlet fever, as it is famil- 
iarly termed. 

History. — A careful reading of the histories of epidemics, in which cu- 
taneous eruptions and inflammations of the throat and glands of the neck 
were prominent symptoms, of which there were many in different parts 
of Europe during the first five or six centuries of the Christian Era, leaves 
no doubt but that scarlet fever constituted a part of several of these epi- 
demics. It was not differentiated from measles, roseola, and some forms 
of angina until the middle of the sixteenth century. In 1556 Ph. In- 
gracsias published an account of an epidemic in Italy, under the name of 
roseola, which was plainly identical with the scarlatina of our time. The 
disease prevailed with considerable severity in London, from 1661 to 1675, 
and was very accurately described by Sydenham, under the name of 
"Febris Scarlatina," in a paper published in 1676. Since that time it has 
prevailed to some extent in all the countries of Europe, and has extended 
to some parts of Asia, Africa and America. Its periods of epidemic prev- 
alence usually continue from one to three years, especially in large cities, 
with intervals of from three to five years of comparative exemption. 
Throughout the temperate zone its greatest prevalence is generally in the 
transition seasons, spring and autumn, though no part of the year is 
exempt from a liability to its prevalence. It often prevails coincidently 
with diphtheria in the same communities ; and sometimes, though rarely, 
some of the more prominent symptoms of both diseases are found existing 
in the same patient. For instance, the inflamed surface of the fauces and 
tonsils may present a well marked diphtheritic coating, while the cuta- 
neous surface is covered with an exanthematous eruption identical with 
scarlet fever. A large majority of the cases of scarlatina occur between 



223 SCARLATINA. 

the ages of two and six years. After six or seven years of age the 
susceptibility to the disease diminishes as the aije increases. Yet rare 
cases have occurred in a few weeks afterbirth and in old age. One attack 
of the disease so far removes the susceptibility to future attacks, that very 
few children have the disease a second time. 

Symptoms. — After a period of incubation, averaging from five to seven 
days, the active symptoms of scarlet fever usually commence abruptly, 
without having been preceded by any prodromic or forming stage. The 
child is first seen to turn pale, and seek its mother's lap or lie down on 
the floor, or on whatever is most convenient, and soon vomits sufficiently 
to reject whatever was contained in the stomach at the time. Sometimes 
the vomiting is accompanied by slight rigors, which last for a few minutes 
only and give place to a rapid access of general fever. The face becomes 
flushed, the skin hot and dry, the pulse and respiration accelerated in 
frequency, the urine scanty and high colored, the bowels natural, with a 
blush of deep redness in the membrane covering the fauces and tonsils, 
and a sense of stiffness or soreness behind the angles of the jaw, causing 
some pain in deglutition, and frequent turns of restlessness. These 
symptoms usually continue about thirty-six hours before the eruption or 
rash appears on the skin, constituting the stage of primary or premonitory 
fever. In mild cases the symptoms just enumerated are moderate, and 
the temperature does not rise above 39° C. (103° F.), and are not 
accompanied by any notable swelling of the glands of the neck. 

During the latter part of the second day, a fine red efflorescence or rash 
begins to show itself ; first on the face, neck and upper part of the chest, 
which extends downward over the trunk of the body and extremities in 
about twenty-four hours, so that by the end of the third day the whole sur- 
face is covered with a fine red rash, pretty evenly diffused, and consisting of 
small red points, neither hard nor elevated so as to be perceptible to the 
touch, and without the slightest appearance of vesicles. The rash rather 
increases in redness for three days, or until the fifth day from the com- 
mencement of sickness, when the whole cutaneous surface presents a bright 
red and finely dotted appearance, and the general febrile symptoms have 
reached their maximum of intensity. From this time the rash begins to 
fade and the general febrile symptoms to abate, and in from two to three 
days more both have disappeared, leaving the patient convalescent in from 
seven to nine days from the commencement of the disease. During the 
decline of the rash, there is much prickling and itching in the surface, 
which becomes rough from the gradual exfoliation of the cuticle. When 
the disease runs the simple course I have now indicated, it is called by 
most writers scarlatina simplex. In a more severe form of the disease, 
the mode of access is the same, but all the symptoms accompanying the 
primary fever are more intense, the temperature often rising to 40° or 41° 
C. (104° to 106° F.), the pulse ranging from 110 to 130 per minute, with 
a proportionate increase in the frequency of respiration, and, in addition, 
the fauces and tonsils become more red and swollen, with rapid swelling 
and tenderness of the glands behind and below the angle of the jaw, 
causing difficulty and pain in swallowing, and adding much to the restless- 
ness of the patient. 

The characteristic eruption or rash appears first on the face and neck, 
about the end of the second day, and increases, as already described, pari 
passu, with a continued increase in the inflammation and tumefaction in the 
fauces and glands of the neck, and the maintenance of the general febrile 
phenomena until the beginning of the fifth day. From this time the rash 
begins to fade and disappears, leaving the skin rough from exfoliation of 



SYMPTOMS. 229 

the cuticle between the seventh and ninth days, as in the scarlatina sim- 
plex. But on the fifth day, when the rash begins to fade, the inflammation 
in the fauces and glands of the neck has only reached its climax. The se- 
cretion from the inflamed mucous membrane, which up to this time had been 
transparent and tenacious, adding much to the embarrassment of breath- 
ing, and causing occasional paroxysms of coughing, now becomes more 
opaque and abundant, and the membrane itself, especially over the tonsils 
and folds of the palate becomes ulcerated, and the glands and tissues be- 
hind the angles of the jaw remain swollen and hard, making it difficult to 
open the mouth wide enough to permit an examination of the throat, and 
equally difficult to administer medicine or nourishment. The local inflam- 
mations cause the pulse to remain frequent, but soft, and the temperature 
above the natural standard, and add much to the exhaustion of the patient. 
But in a considerable proportion of these cases, after the end of the first 
week, the swelling of the glands slowly diminishes, the ulcerations in the 
fauces and throat cease to spread and gradually take on a reparative ac- 
tion, and by the end of the second week, convalescence is fairly establish- 
ed. In cases a little more severe, the inflammation, about the fifth or sixth 
day. extends from the fauces into the posterior nares, and soon involves the 
whole Schneiderian membrane, obstructing the nostrils and causing a mu- 
co-purulent discharge, sometimes offensive, and adding much to the dis- 
comfort of the patient. During the same time, in a smaller number of 
cases, the inflammation extends through the eustachian tube to the middle 
ear, causing pain, suppuration, perforation of the tympanum and purulent 
discharge from the external meatus. 

In a large proportion of these cases, if recovery from the acute general 
disease takes place, there remains a chronic otitis with permanent im- 
pairment of hearing. In many of the cases presenting severe inflammation 
in the throat, glands of the neck, nostrils and ears, the respiration and 
deglutition become so much obstructed that, somewhere between the fifth 
and ninth days, the pulse becomes very small, frequent and feeble ; res- 
piration irregular and frequent ; the temperature high ; urine very scanty 
and often albuminous ; the mind dull and inclined to sleep, but often 
roused to paroxysms of great restlessness by the obstruction in the throat: 
soon the hands and feet begin to feel cold and look leaden color or purple; 
and the patient dies apparently from exhaustion. In some of this class 
of cases, gangrene attacks the tonsils and other more intensely inflamed 
parts of the fauces, causing the breath to be very offensive, and adding to 
the rapidity of the exhaustion. All the cases accompanied by the 
different degrees of inflammation and tumefaction of the glands of the 
neck, as I have just described, are included by writers under the head of 
scarlatina anginosa. In nearly all of the more severe epidemics of 
scarlatina, cases are met with in which, from the very beginning of active 
symptoms, the pulse becomes extremely frequent and feeble; the temper- 
ature from 41° to 43° C. (106° to 110° F.) ; respiration, irregular and 
panting, like one tired; the surface more or less congested and sometimes 
mottled with purplish spots ; the extremities cool and blue or leaden color; 
the mind dull and sometimes incoherent, with paroxysms of great restless- 
ness; and, in some, there is swelling of the glands of the neck, and in others 
none. In most of these cases the characteristic exanthem or rash makes 
its appearance on the evening of the second day, and is often accom- 
panied by petechial spots, increasing exhaustion and death between the 
third and fifth days. I have seen a few cases in which death took 
place in from twenty-four to thirty-six hours after the initial symptoms. 
The cases presenting the symptoms just detailed present all the character- 



230 SCARLATINA. 

istics of malignancy, and constitute a group described by authors under 
the name of scarlatina 'maligna. 

You will notice, from the detail of symptoms I have given, that scarlatina 
varies very much in the degree of its severity in different cases — from a 
very mild, simple, irritative fever, of short duration, and uniformly tending 
to recovery, to one of the most malignant and rapidly fatal that the phy- 
sician has to encounter. And cases are met with presenting every grada- 
tion between these extremes, leaving no well-defined line of separa- 
tion between those designated as scarlatina simplex, scarlatina anginosa, 
and scarlatina maligna. Consequently you must understand these 
terms as indicating simply different degrees of severity, both in general 
phenonema and in local complications. There are not only great differ- 
ences in the severity of different cases in the same season, but equal 
diversities in the character of different epidemics. I have known several 
epidemics, in which large numbers were attacked, and nearly all the cases 
were of the simple, or moderately anginose variety. I have witnessed 
other epidemics in which a large proportion of all the attacks were severely 
anginose or malignant. 

Diagnosis. — Scarlatina, in all grades of its severity, is distinguished 
from variola and varioloid by the shorter duration of the primary fever 
before the eruption, the greater frequency of pulse and respiration, the 
bright redness in the fauces with tumefaction of the tonsils, and, in many 
cases, swelling of the lymphatic glands in the parotid and sub-maxillary 
regions, and still more by the character of the eruption when it appears; 
the latter consisting of very small red points with general redness of the 
surface, but neither elevated nor hard to the touch, while that of variola 
and varioloid is both, with a small vesicle on the top; and that of varicella 
is equally prominent and more largely vesicular from the beginning. 
From rubeola, or measles, it is distinguished by the absence of the coryza, 
cough and other catarrhal symptoms that accompany the latter; by the 
greater intensity of the fever; the earlier appearance of the eruption; 
and the smaller and more evenly diffused red points that constitute the 
rash or exanthem. The same characteristics also distinguish it from 
rbtheln and roseola. 

Prognosis. — The prognosis in cases of scarlatina simplex is always 
favorable, so far as the direct results of the fever are concerned. But ex- 
perience has shown that even the mildest cases are liable to be followed, 
during convalescence, by that form of acute renal congestion which speed- 
ily develops general dropsical swelling, insufficient excretion of urea and 
other elements of urine, and consequent dangerous poisoning of the nerv- 
ous centers. The anginose variety of scarlatina is dangerous in proportion 
to the extent and intensity of the inflammation in the fauces and adja- 
cent lymphatic glands. During the active progress of cases belonging to 
this grade of the disease, the urine sometimes becomes scanty and con- 
tains both albumen and tubular casts, indicating a dangerous degree of 
renal congestion. In a small proportion of cases, convulsions occur, 
either at the beginning or during the progress of the primary fever, and 
add much to the gravity of the disease. Cases complicated by the ap- 
pearance of diphtheritic exudations on the membrane lining the fauces, 
posterior nares, or larynx, are very liable to terminate fatally. The prog- 
nosis, in cases of a true malignant character, is extremely unfavorable, 
recoveries being exceptions to the general rule. Adults, when attacked 
by scarlatina in any of its grades, are even more liable to a fatal result 
than children. When it attacks a pregnant woman it creates a strong 
tendency to a miscarriage or a premature labor, and is very apt to terminate 
fatally, although some cases of this kind have recovered. 



PATHOLOGICAL CHANGES. 231 

Pathological Changes. — The morbid changes which take place dur- 
ing the progress of scarlet fever, are chiefly such as result from the 
inflammations in the skin, mucous membrane of the fauces, glands of 
the neck and kidneys. Each exanthein or red point on the cutaneous surface 
is caused by an inflammatory congestion of the vessels of the corium, or layer 
immediately beneath the epidermis, with a slight accumulation of lymphoid 
cells. In all ordinary cases there is not sufficient exudation to cause any 
elevation or hardness, and even the redness mostly disappears after death. 
In some instances in which the rash was strongly developed, slight extra- 
vasations of serum and blood corpuscles have been discovered in the rete 
malpighii and in the lumen of the sweat-glands. The congestion of the 
vessels is sufficient to interrupt the natural relations between the cutis 
vera and the epidermis, so far as to cause a very general exfoliation of the 
latter on the subsidence of the cutaneous inflammation. The exfoli- 
ation over the surface generally is in the form of thin lamina, but in the 
palms of the hands and soles of the feet it sometimes separates in large 
thick layers. In all the anginose cases the mucous membrane covering the 
fauces, tonsils and pharynx is found intensely red from congestion of 
blood in the vessels, more or less swollen, and often ulcerated or, in 
patches, destroyed by gangrene. In many cases the mucous membrane lin- 
ing the posterior and middle part of the nostrils is in the same condition. 
In the same class of cases the tonsils and many of the adjacent lymphatic 
glands are much tumefied fiom congestion of vessels, exudation of white 
corpuscles and plastic material and sometimes the formation of abscesses 
from a true phlegmonous inflammation. The inflammation and suppura- 
tion often extend into the connective tissue behind and beneath the angle 
of the jaw ; and, in some cases, burrow in behind the pharynx, and 
not only render breathing and deglutition difficult, but sometimes break 
and discharge the matter into the pharynx so fast as to be drawn into the 
larynx and cause suffocation. 

A case terminated fatally from this cause, under my own care, nearly 
forty years since. The patient was a female child about two years of age, 
who had passed through the active stage of severe scarlatina anginosa, 
during which the glands and connective tissue near the angle of the jaw 
became very much swollen and hard. Suppuration took place deep be- 
neath the faciae of the neck, and extended inward and downward behind 
the lower part of the pharynx, and before distinctly pointing externally, 
broke almost opposite the epiglottis, and filled the throat so rapidly as to 
cause immediate suffocation. Post-mortem examinations also show, in 
some cases, severe inflammation and suppuration in the middle ear, with 
perforation of the tympanum, and sometimes necrosis of the small bones. 
In some epidemics of scarlatina, the mucous membrane covering the tonsils 
and other parts of the fauces, has been found covered with a layer of 
fibrinous exudation, closely resembling, if not identical with, the mem- 
branous exudation in diphtheria. 

Heubner has attempted to show that the membrane thus seen in some 
cases of scarlatina is not identical with that of true diphtheria, but is 
thinner, and disintegrates without ever being detached or expectorated in 
shreds or patches. He also claims that scarlatinal fibrinous material is 
exuded beneath the epithelial cells and into the connective tksie of the 
submucosa. All parties admit, however, that the micrococci found present 
in the exudation are the same in both diseases. Having, in my own ex- 
perience, never seen fibrinous exudations on the tonsils and fauces of 
scarlatina patients, except when diphtheria was more or less prevalent in 
the community at the same time, I have regarded its presence as evidence 



232 SCARLATINA. 

that the causes of both diseases were influencing the patient coincidently, 
similar to the coincident action of the causes of typhoid and periodical 
fevers, in producing what has been called typho-malarial fevers. 

The frequent occurrence of albumen in the urine, during the progress 
of scarlet fever, and of the marked evidences of inflammatory congestion 
of the secreting structure of the kidneys alter death, renders it probable 
that the scarlatina poison, or contagium has much the same affinity for the 
renal tubules, that it has for the skin. In many post-mortem examina- 
tions the kidneys were found enlarged and pale externally, with marked con- 
gestion of the vessels connected with the tubules and glomeruli, and de- 
tached epithelial cells filling and obstructing the former. It is this action 
of the scarlatina poison on the renal organs, that determines the frequent 
occurrence of acute and chronic renal affections, accompanied by dropsical 
symptoms as sequelas of the general disease. 

Complications and Sequelw. — The most important complications occa- 
sionally met with during the progress of scarlatina, are lobular pneumonia, 
nephritis, pericarditis, convulsions, and sub-acute articular rheumatism; 
while chronic otitis, with purulent discharges, acute and chronic renal 
congestions and degenerations, with dropsical accumulations, rheumatism, 
chorea, and general anemia, constitute the most frequent and important 
sequelae. The complications mentioned may occur at any time during the 
active progress of the general disease; but they are most apt to be devel- 
oped between the fifth and ninth days after the commencement of the fe- 
ver, that is, during the decline of the eruptive stage. The various seque- 
la3 may begin at any time during the convalescence, or within from one to 
six weeks after the beginning of the desquamation of the cuticle. 

Treatment. — The objects to be accomplished in the treatment of scar- 
let fever, may be stated as follows: 

First, to remove the further action of any predisposing causes that may 
exist, and to neutralize or destroy the specific contagium in the system. 
Second, to lessen the direct irritative and disturbing action of the specific 
cause on the properties of and molecular changes in the blood and organized 
structures of the body, by such remedies as allay morbid, excitability, 
lessen temperature, and promote natural secretory action. Third, to les- 
sen the severity of the local inflammations, especially in the throat, glands 
of the neck and kidneys. Fourth, to sustain the nutrition and strength 
of the patient, and promote the repair of such structures as may have 
suffered injury during the active progress of the disease. 

As the predisposing causes of scarlatina are chiefly impure air from 
imperfect ventilation, uncleanliness and bad sewerage, so, when cases of 
the disease actually exist, the attending physician can not be too careful 
to have his patient freed from the furthur influence of all such unsanitary 
conditions. It is very important that the room of the scarlet-fever 
patient should be well ventilated, cleanly, and kept at a temperature 
no higher than is pleasant for a person in good health. Neither should 
the child be wrapped in any unusual amount of clothing. You will 
find many families manifesting a persistent determination to violate these 
rules. As soon as they are aware that a child has this variety of fever, 
they will have it closely bundled from head to foot with all the shawls 
and blankets they can get around it, have all the doors and windows 
closely shut, and heat the room to an uncomfortable degree. 

They could hardly do anything that would have a more debilitating in- 
fluence, or render the patient more susceptible to cold, or more disposed 
to suffer from renal congestion and dropsical effusions during the conva- 
lescence. In regard to remedies for destroying or neutralizing the speci- 



TREATMENT. 233 

fie contagium in the system, and thereby arresting its further disturbing 
influence, we have none that have proved efficient or entirely successful 
when subjected to the test of direct clinical experience. Many have been 
tried, and received more or less commendation; the more important of 
which are iodine, chlorine in solution with chlorate of potassium, perman- 
ganate of potassium, the hyposulphite of sodium or calcium, sulpho-carbolate 
of sodium, benzoic acid, and the benzoate of sodium. I have used all these 
remedies, more or less, in the treatment of the early stage of scarlatina. 
In some instances they appeared to lessen the severity of the symptoms 
and favorably modify the progress of the disease, but in no instance have 
I seen the disease arrested or rendered abortive, as though its essential 
cause had been destroyed. For fulfilling the second indication speci- 
fied, the most safe and efficient remedy is the frequent sponging of the whole 
surface with cold water, and, in bad cases, the application of the wet 
sheet with the sprinkling, in the same manner as I have detailed when 
speaking of the treatment of typhoid fever. Judiciously used, it will do 
more to allay the extreme excitability, lessen the temperature, and favor 
natural molecular changes during the first four or five days, than can be 
done by all other remedies. It was chielly in the treatment of scarlet fever 
that Dr. Currie, of London, demonstrated the value of free applications 
of cold water to the surface as an antipyretic, more than a century since. 
The common fear that frequent sponging of the cutaneous surface with wa- 
ter will prevent or repel the eruption is entirely without foundation. I 
think it was Dr. Anderson, of Alabama, who, in describing one of the most 
malignant epidemics of scarlet fever that ever occurred in that State, 
spoke of the thorough application of cold water to the surface as one of 
the most efficient means adopted for the relief of the more severe cases. 

The epidemic to which I allude prevailed prior to 1850, and the paper 
of Dr. Anderson was published in one of the volumes of Fenner's Southern 
Medical Reports, which I have not now at hand for accurate reference. 
In a report made to the Scott County Medical Society, in 1850, Dr. W. L. 
Sutton, of Georgetown, Ky., says, in commenting on the treatment of 
scarlatina,, as it prevailed in that State, "the external application of water, 
cold or warm, is inferior to no other remedy."* Dr. R. K. Smith, of Dela- 
ware county, Penn., in speaking of the treatment of an epidemic of this fever, 
prevalent in that county in 1851, says the treatment most successful in his 
hands was " cold ablutions, followed by cold inunction with lard and neutral 
mixture, and aperient medicines internally." Dr. Hiram Corson, of Mont- 
gomery County, Pa., alluding to the prevalence of the fever in that county, 
the same year, expresses " great confidence in the efficacy of cold affusions." 
Similar testimony is borne by Drs. J. P. Heister, of Reading, and N. Hayes 
Clark, of Newark, the same year.j- I give you. these references for two pur- 
poses, namely : to show that the free application of water to the surface in 
the treatment of scarlet fever has been practised by many American physi- 
cians for half a century; and that the effect in reducing temperature, less- 
ening excitability and restlessness, and promoting normal actions in the 
system, is as prompt and beneficial as when applied to cases of typhoid, 
typhus, or any of the other acute general diseases. 

For further correcting the general derangements of secretory and molec- 
ular action in the severe anginose cases, three or four alterative doses of 
calomel, given during the first twenty-four hours, and the subsequent use 
of the aqueous solution of iodine, in doses suited to the age of the patient, 
constitute as efficient measures as jve can adopt. I deem it important to 

* See Transactions of the Amer. Med. Association, Vol. IV, p. 120. 1851. 

t See Transactions of the Amer. Med. Association, Vol. V, pp. 121, 2, 5, and 41, 1852. 



231 SCAELATINA. 

avoid all active evacuants, as emetics and cathartics during- the first two 
days, as liable to divert the specific cause or contagium from its natural 
tendency to lodgment in the cutaneous surface and favor its retention in 
the blood. Such movements of the bowels as may be necessary, can usually 
be obtained by warm water enemas. To lessen the severity of the local in- 
flammations in the fauces and glands of the neck, besides the general 
remedies already mentioned, keeping the swollen parts covered exter- 
nally by the continuous application of pounded ice inclosed in bladders, or 
light, soft rubber bags, during the first three or four days, will be found 
highly beneficial in the more active anginose cases. But if the ice is not at 
hand, or if the parents are too strongly prejudiced against cold applica- 
tions, you can cover the swollen parts with cloths kept wet with an infusion 
of aconite leaves and muriate of ammonium. The infusion may be made by 
putting one litre (two pints) of water boiling hot on thirty-two grams 
(31) of aconite leaves, and sixteen grams (3SS) of ammonii murias, in any 
convenient vessel, stirring them several times while cooling, aud use it 
only milk warm. It really constitutes a cooling, narcotic, and discutient 
application, that T have used as an external application during the first 
three or four days, both in scarlet fever and diphtheria for many years, 
and with much apparent benefit. 

For the inflamed parts in the fauces and throat, during the same stage 
of the disease, I know of no better application than a dilute solution of 
chlorate of potassium, containing a small proportion of hydrochloric acid 
and tincture of belladonna, used in the same manner as I directed when 
speaking of the treatment of diphtheria.* When the first stage is passed, 
and the fever and rash begin to decline, if the swollen glands remain hard 
and but little disposed to undergo resolution, the application, three times a 
day, of a liniment composed of three parts of camphorated soap 
liniment and one part of tincture of iodine, may be used instead of the 
infusion or ice. At the same stage, the internal use of the chlorate of 
potassium and belladonna solution should be exchanged for suitable 
doses of the tincture of the chloride of iron and quinine, both for their 
local effect on the throat, and tonic and antiseptic effect upon the system 
at large. In cases presenting unusual weakness and frequency of 
pulse, the administration of suitable doses of a solution containing liquor 
ammonias acetatis, tincture of digitalis and carbonate of ammonium, 
between the doses of the tincture of iron and quinine, may be given 
with great benefit. In the fulfillment of the fourth indication I have 
named, careful attention should be given throughout the whole course of 
the disease, and especially during its middle and later stage?, to the 
administration of nourishments, of which good milk, thin wheat flour and 
milk gruel, and beef tea, are the best. They should be given in small 
quantities at a time, but repeated sufficiently often to supply a fair degree 
of nutrition. When the swelling or ulcerations in the throat are such as 
to render the swallowing of nourishment very difficult, a nutritive enema, 
consisting of milk or good beef tea should be given per rectum morning 
and evening. Such cases can be further sustained by applying, two or 
three times a day, over a large part of the cutaneous surface, cod-liver oil, 
holding in suspension a small quantity of sulphate of quinia. In the more 
malignant cases of scarlatina anginosa, in which incipient appearances of 
gangrene are presented in the fauces or tonsils, between the third and 
fifth days, I have been in the habit of ordering an infusion of four grams 
(3i) of cayenne pepper in 130 cubic centimeters (fl. §iv) of boiling milk, and 
when cool, giving to a child five years of age, one teaspoonful ewerj one 

* See formula and directions on page 174. 



PROPHYLAXIS. 235 

or two hours, until the critical stage is passed and the sloughs separated, 
leaving- clean, ulcerated surfaces, when the pepper is omitted, and only 
slightly astringent and soothing gargles used locally, with quinine, iron 
and nourishment internally. 

In some cases of the more malignant grade of scarlet fever, accompa- 
nied by a high temperature, very frequent pulse, hurried breathing and 
dullness or drowsiness between the paroxysms of restless tossing, I have 
caused the whole surface to be thoroughly sponged with cool water every 
three or four hours and this to be followed by an application of cod- 
liver oil containing a small proportion of iodine; and apparently with de- 
cided benefit. It is not long since that I was called to a family on Fif- 
teenth street, west of State street, where three children had been attacked 
with the fever in a very malignant form. One was already dead, having 
been sick only three days; another was dying; and the third, a little boy, 
who had sickened two days later than the other two, was rapidly develop- 
ing the same symptoms, and the characteristic eruption had appeared 
thickly over the surface. He was put upon the use of such internal 
remedies as I have already indicated, and faithfully sponged with the cool 
water followed by the application of the iodized oil as just described. The 
spongings were followed by such marked improvement in the pulse, temper- 
ature, and nervous sensibility, as to leave no doubt of their beneficial effect. 
The case ran a severe course, but recovered without any bad sequelae. 
Having indicated as clearly as possible the several objects to be ac- 
complished in the treatment of the different grades and stages of scarlet 
fever, and the means I have found best adapted to the accomplishment of 
these objects, I will only remark further that the milder cases of scarla- 
tina simplex need but little medicine of any kind. A moderate dose of 
the solution of chlorate of potassium, hydrochloric acid and belladonna* 
three or four times a day with the proper hygienic regulations, is all that 
is required in such cases. 

Prophylaxis. — Isolation of the sick as far as practicable, and faithful 
attention to cleanliness, ventilation, and proper disinfection, constitute the 
best means for limiting the spread of the disease. Much has been writ- 
ten in relation to the efficacy of belladonna and other remedies to be given 
internally as preventives of scarlet fever. The fact that the period of 
ncubation of this disease is not well-defined, coupled with the further 
important fact that many children who are fully exposed to contact with 
it, do not take the disease when no preventive means have been used, 
renders it very difficult to determine the actual value of any given drug 
when administered for this purpose. In cases where the date of exposure 
to the contagium is known, and the patient can commence immediately, or 
at least as early as the second day, the taking of fair doses of a solution of 
the hyposulphite of sodium with tincture of belladonna, three or four 
times a day until the time for active symptoms of the fever to begin had 
passed, I feel confident that the development of the disease would be 
either entirely prevented, or its attack rendered very mild. For a child 
five years of age, the dose of the hyposulphite should be from three to 
five decigrams (gr. v to viii) with tincture of belladonna 0.13 cubic 
centimeter (min. ii), dissolved in mint water. 

Sequelae. — Scarlet fever, more than any other one of the acute general 
diseases, is liable to be followed by troublesome and important sequelae. 
Inflammation and suppuration in the middle ear, followed by perforation 
of the tympanum and a protracted purulent discharge from the exter- 
nal meatus, with more or less impairment of hearing, are of frequent 
occurrence both during the advanced stage of severe anginose cases, and 

*See page \1\. 



230 SCARLATINA. 

during any purl of the period of convalescence, from attacks even of the 
mildest charaoter. The commencement of the inflammation is indicated 
)>y the occurrence of sharp, lancinating, or throbbing pains in the ear; an 
increase of fever and restlessness ; and sometimes delirium. 

These symptoms generally continue with increasing severity from two 
to four days, when a discharge commences from the external ear, followed 
by a rapid subsidence of the pain ami i'ovcr. Jn many eases the discharge 
is at first a thin serous fluid, quite abundant in quantity, which subse- 
quently diminishes and becomes more purulent; while in other eases it is 
a thick- white pus from the, beginning. In a large proportion of the cases, 
the discharge and the other local symptoms, cease altogether in from one 
to two weeks, leaving the hearing unimpaired; while in others it contin- 
ues indefinitely and is accompanied by partial or complete destruction of 

the tympanum, a-nd sometimes loss of one or more of the small bones of 

the ear, with partial or complete deafness. For the treatment of these 
cases I refer you to the lecture on otitis, in its various forms and stages. 
Another painful and sometimes protracted serpiel is sub-acute rheumatism. 
It generally commences in the early part of convalescence, and is most 
apt to attack the wrists, ankles, and smaller joints of the hands and feet, 
but sometimes extends over nearly all the articulations of the extremities 
and trunk of the body, and even to the structures of the heart. It is 
best relieved by the same remedies that have been found effectual in 
similar grades of rheumatic inflammation, occurring- unconnected with 
scarlet i\>A'<>v, and which are fully considered in the lectures on acute and 
chronic rheumatism. 

But perhaps the most important and dangerous, if not the most frequent 
sequel of scarlatina, is some degree of nephritis or renal congestion, ac- 
companied by more or less anasarca or general dropsy. During the active 
stage of the general i'aver^ the urine is often found containing albumen and 
other evidences of renal congestion and irritation, which should never be 
overlooked or neglected by the attending physician. All the facts appear 
to show that there is some quality of the essential cause of the fever, which 
so influences the renal structures as to leave them during the convales- 
cence, peculiarly susceptible or predisposed to inflammatory congestions 
of all degrees of severity. The common impression is, that the renal 
dropsies following scarlatina are caused by undue exposures to cold or go- 
ing out too soon; but my own experience does not sustain that impression. 
On the contrary, a large majority of the cases which have come under my 
observation, have been in children who had been kept in rooms too warm 
and too little ventilated, and have used more or less of alcoholic remedies as 
a part of their treatment. The renal affections following scarlatina may 
commence at any time during the four weeks following the subsidence of 
the general fever ; but much the larger number of cases are noticed be- 
tween the third and tenth days after the beginning of convalescence. They 
vary much in severity, and mode of development, from a very acute and 
dangerous nephritis to a simple passive congestion sufficient to cause the 
exudation of albumen in the urine. But, as all these affections are fully 
considered in the lectures on acute and chronic nephritis, including the 
various pathological conditions causing albumen to be eliminated in the 
urine, it would involve unnecessary repetition to enter further into their 
discussion at this time. I will only add, therefore, that you should not 
only pay special attention to the renal secretion during the active progress 
of all cases of scarlatina, applying proper tests for albumen as often as ev- 
ery second day, but you should always instruct the patient or the nurse to 
keep close watch of the quantity and appearance of the urine until the 



RUBEOLA. 237 

period of convalescence is passed. It is a good rule, in cases presenting 
albuminous urine during- the active stage of the fever, to give all through 
t ho stage of convalescence, moderate doses of spirits of nitrous ether 
with tincture of chloride of iron, three times a day, well diluted with 
water. 



LECTURE XXVI. 

Rubeola— Rotheln— Roseola— Pertussis and Mumps— Their History, Causes, Symptoms, Diagnosis 
and Treatment. 

GENTLEMEN: In this country the word rubeola has been pretty uni- 
formly used to designate the disease called morbilli or measles. But in 
recent times many English and Continental writers (Aitken, Reynolds, 
Trousseau, Thomas in Ziemssen, etc.) have applied it to a hybrid disease 
known in this country as rotheln, or "German measles." By others the 
latter has also been called roseola; thereby producing much confusion in 
the application of names, and no little embarrassment to the student in 
his efforts to preserve a clear, differential diagnosis between these several 
milder exanthematous diseases. I shall adhere to the American custom 
of regarding rubeola, morbilli and measles, as synonyms, applicable to 
true measles only. The hybrid disease intermediate between scarlet 
fever and true measles I shall call rotheln; while roseola will be used to 
designate a very mild febrile affection, non-contagious, and characterized 
by the appearance upon the skin of red spots instead of exanthematous 
points. 

Rubeola, or measles, is a contagious eruptive fever of much milder 
character than variola or scarlatina, and though not accurately differen- 
tiated from the latter, the description of it is easily recognized in the 
history of some of the epidemics that occurred in the early part of the 
Christian era. Like scarlet fever, it attacks mostly children and youth, 
though it may attack persons at any period of life; and suffering from it 
once usually destroys the susceptibility to the action of the specific cause 
through the remainder of life. Yet there are many who have had the 
disease twice or even thrice. Throughout the temperate zone, it is most 
apt to prevail in the transition seasons, spring and autumn, though no part 
of the year is exempt. While in enlightened countries where the nature 
of the disease is well understood, and reasonable attention is given to 
hygienic and sanitary measures, it is regarded as of but little importance; 
its introduction into some countries of less enlightened people, has been 
followed by a serious degree of fatality. For instance, an extensive prev- 
laence of the disease in Japan, in 1861, according to the statements of 
Dr. D. B. Simmers, destroyed 75,000 lives; and in the Fiji Islands, iri 
1875, it is said to have destroyed the lives of one-fifth of the entire popu- 
lation. The measles that prevailed quite extensively in some of the 
military camps for the rendezvous and training of recruits, during the 
late war in this country, was accompanied by a considerable ratio of 
mortality, owing chiefly, however, to pneumonic and typhoid complica- 
tions. 

Causes. — The predisposing causes that favor the development and spread 



238 RUBEOLA. 

of rubeola, are youth, overcrowding and bad ventilation, uncleanliness, and 
damp, cold air. The essential cause is a specific contagiurn formed in the 
bodies of the sick, and eliminated chiefly through the skin and lungs, con- 
taminating the air immediately around the patient, and capable of com- 
municating the disease to other persons who breathe it, and capable also 
of becoming attached to clothing, and being transferred to other places. 
Like all the other contagiums and miasms, this has been regarded by 
modern investigators as composed of organic germs. Dr. J.H. Salisbury, 
of Cleveland, Ohio, claimed to have discovered the specific cause to be a 
species of fungus developed on damp straw, and thus attempted to explain 
ttie prevalence of the disease in some of the military camps connected 
with our army. His observations, however, were not confirmed by those of 
Drs. Hammond, Woodward, and others, who gave special attention to the 
subject ; and it is highly probable that the irritation of the air passages 
and slight fever, sometimes produced by the fungus developed on damp 
straw, is entirely distinct from true measles. That the specific cause or 
contagiurn is developed in the blood of patients laboring under the 
disease, is proved by the results of inoculations, by which the disease is 
readily communicated. 

Symptoms. — After an incubative stage varying from nine to fourteen 
days, the active symptoms commence with slight alternations of heat and 
cold accompanied by some headache, a general sense of weariness, moder- 
ate heat of skin, slight acceleration of pulse, a marked sense of tightness 
or oppression in the chest with dry harsh cough, fullness and dryness of 
the nostrils, red and watery appearance of the eyes, and flushing of the 
face. In other words, all the usual symtoms of an attack of influenza, or 
a severe " common cold." All these symptoms gradually increase in 
severity until the evening of the fourth day, when generally there is much 
redness of the face and eyes, sensitiveness to light, a severe hoarse rough 
cough sending a sore pain through the anterior part of the head and 
temples, with very decided soreness and sense of oppression in the chest ; 
moderate fullness and acceleration of pulse ; temperature from 39 c to 
40° C. (102° to 104° F.) ; and scattered over the face and upper part of 
the chest an eruption of small red points, a little larger than the points or 
exanthems of scarlatina, and more irregular in distribution ; there being 
in some places two or more points clustered together, and in others 
but one, leaving the skin of natural color between them. There are no 
hard elevated papules either with or without vesicles, but simple red 
points hardly perceptible to the touch as the finger is passed over them. 

The eruption thus commenced on the face, neck and chest, rapidly extends 
over the whole cutaneous surface, reaching the extremities about the end of 
the fifth day, or twenty-four hours later than its appearance on the face. 
All the local catarrhal and general febrile symptoms continue unabated 
until the third day of the eruption, or the seventh from the commence- 
ment of active symptoms, when the disease has reached its climax, and 
the next day both the fever and rash have notably diminished. All the 
symptoms now decline steadily, until convalescence is fully established, 
generally between the tenth and twelfth days from the commencement of 
catarrhal symptoms. The disappearance of the rash is followed by slight 
desquamation or roughness, but not so much as after scarlatina; and a 
moderate bronchial cough often lingers through the convalescence. The 
general character of the symptoms, and the order of their occurrence in 
measles, are more uniform than in any of the other eruptive fevers. You 
will meet with some cases, however, in which the febrile symptoms and 
the amount of the eruption will be less than I have described, and others 



DIAGNOSIS AND PROGNOSIS. 239 

in which they are m ire severe. In some of the latter class, at the time 
of the appearance of the eruption, the temperature may rise to 40.5° or 
41° C. (105° or 100° F.); the eruption overthe face and neck so thick as to 
make the whole surface red, and the eves so irritable that the patient will 
no open them to the light. The soreness in the chest, and cough, are 
very severe, with tenacious mucous expectoration, and such a degree of 
nervous disturbance as to cause some delirium, especially in the night. A 
very small proportion of these unusually severe cases present a decidedly 
malignant aspect. Such cases, in addition to the high temperature, and 
other severe symptoms just named, present a frequent and feeble pulse ; 
irregular and oppressed breathing ; and generally more or less of petech- 
ial or hemorrhagic spots in connection with the eruption. The extrava- 
sated blood is dark, purplish color, and gives to the cutaneous surface a 
peculiarly dark and spotted appearance, which has given origin to the 
name of " black measles.''' 1 The petechial spots more frequently appear 
over the abdomen, inside of the thighs and legs, but may extend to the 
face, and other parts of the surface, and are sometimes accompanied by 
hemorrhage from the mouth, gums, nostrils, or from the mucous membrane 
lining the stomach and lower bowels. It is only a few months since I saw 
a case of this kind, in the person of a young woman, which terminated 
fatally on the third day after the appearance of the eruption. 

Diagnosis. — Rubeola is distinguished from all the other eruptive fevers 
by the presence of the severe catarrhal symptoms from the beginning. From 
variola, varioloid, and varicella, it is further distinguished by the absence 
of all elevated and hard pimples and vesicles, and instead, the presence of 
small red points or exanthems, which differ from those of scarlet fever in 
being irregularly distributed in clusters instead of uniformly diffused 
over the cutaneous surface. 

Prognosis. — Except the very few cases of a special malignant character 
uncomplicated cases of measles uniformly tend to recovery; consequently 
the ratio of mortality resulting from its prevalence is very small. Yet 
you will find in the annual statistics of mortality, quite a number of deaths 
attributed to measles. Judging from my own observations, I should say that 
three out of every four of these deaths were caused by the supervention of 
broncho-pneumonia during the eruptive stage of the general fever. This 
complication is most apt to occur in young children, and in such adults as 
are living in overcrowded or badly ventilated places. In the latter class of 
cases dysentery is also liable to occur, especially in the advanced stage of the 
fever, and sometimes is sufficiently severe to cause the death of the patient. 
It was the supervention of pneumonia and dysentery as complications, that 
caused nearly all the deaths resulting from the prevalence of measles in 
the military camps during the recent war in this country. Another com- 
plication that occasionally occurs, though less frequently than in connec- 
tion with variola and scarlatina, is general convulsions. Such attacks are 
most apt to occur in children under five years of age, and just at the stage 
when the eruption is first beginning to appear on the surface. 

Pathological Anatomy. — As this disease rarely terminates fatally, 
except when influenced by some important complication, so there are no 
structural changes to be found after death peculiar to measles, ex- 
cept the eruption which appears on the mucous membrane of the air 
passages, causing the catarrhal symptoms, and subsequently upon the 
cutaneous surface. This does not differ anatomically from the efflores- 
cence in scarlatina, which I described sufficiently in the preceding 
lecture. 

Treatment. — As rubeola is a self-limited disease, tending generally 



45 c. c. 


liss 


15 c. c. 


§ss 


60 c. c. 


i" 



240 RUBEOLA. 

to the recovery of the patient, there is no need of very active medica- 
tion. The same attention should be given to the temperature, cleanli- 
ness, and ventilation of the sick-room as in scarlatina ; and the same 
avoidance of hot stimulating drinks and excessive clothing. As we 
know of no specific remedy capable of destroying the contagium or 
essential cause so as to arrest the progress of the disease in its early 
stage, the chief objects to be accomplished are, to lessen the severity of 
the cough and soreness in the chest, and promote natural secretory actions. 
To mitigate the cough and other catarrhal symptoms, I have found the 
following combination one of the best : 

1$, Sj^rupus Scillae Compositi 
Tincturae Sanguinariae 
Tincturae Opii Camphoratae 

Mix, and give to an adult four cubic centimeters (fl 3i) every three or four 
hours, in a tablespoonful of water. In cases accompanied by very severe 
headache, 16 grams (3iv) of potassium bromide maybe added to the form- 
ula with advantage. Or if, as sometimes happens, the fever is unusually 
severe, the addition to the same formula of four cubic centimeters (fl. 3i) 
of the tincture of veratrum viride, will render it more efficient in reliev- 
ing the patient during the first three or four days, or until the crisis of the 
disease is passed. During the first three days of treatment, if the fever is 
active, tongue coated, and urinary secretion scanty, 1 give an anodyne dose 
of the compound powder of opium and ipecac (Dover's powder) with from 
six to twenty centigrams (gr. i to iii) of calomel each night and follow it 
by some mild saline laxative in the morning. In the milder cases, this is 
not necessary. After the third day of the eruption, in the great majority 
of cases, no other medicine is required than a mild anodyne expectorant 
three or four times a day until the cough disappears. Those rare cases of 
a malignant or haemorrhagic character, when encountered, must be treated 
in the same manner as I indicated when speaking of the management of 
cases of malignant variola. If capillary bronchitis, lobular pneumonia, or 
other local inflammations supervene as complications during the progress of 
any grade of rubeola, they must be treated in the same manner as similar 
grades of inflammation occurring under other circumstances. 

Sequelae. — The most frequent and important diseases observed to fol- 
low attacks of measles, are chronic inflammations of the conjunctiva and 
tarsus of the eyelids, chronic bronchitis, scrofulous adenitis, and phthisis. 
It is probable that these results are restricted mostly to persons who 
possessed some degree of hereditary predisposition to scrofula or tuber- 
culosis, prior to the attack of the eruptive fever. But there appears to 
be something in the nature of the changes produced in the blood and the 
properties of the tissues during the progress of measles that directly in- 
crease these predispositions and strongly tend to convert them from a 
latent to an actively developing progress. For this reason, we find many 
cases of well-developed phthisis, particularly between the ages of twelve 
and twenty years, in which the cough is very definitely dated back to the 
time when they had the measles. For the purpose of more effectually 
preventing such results, the attending physician should look closely both 
to the family tendencies and the individual temperament, in all cases of 
this form of eruptive fever. And when either scrofulous or tuberculous 
tendencies are discovered, as soon as the febrile stage is passed and con- 
valescence commenced, the patient should be put at once upon such rem- 
edies and diet as are best calculated to counteract such tendencies. Among 



ROTHELN. 241 

the remedies usually resorted to, I know of none better for this class of 
cases, than a mixture of two parts of the syrup of iodide of calcium with 
one of fluid extract of hops, given in doses of three to six cubic centi- 
meters (fl 3ss to 3iss), according to the age of the patient, and repeated after 
each meal-time. The lacto-phosphate of calcium, the compound syrup of 
hypophosphites, and cod-liver oil, may be used for the same purpose. As 
far as possible, such cases should live in dry, well- ventilated rooms; take 
plenty of plain, easily digestible food, and moderate but habitual out-door 
exercise. When some degree of cough, with moderate loss of flesh, con- 
tinues for some time after convalescence is completed, a change to a mild, 
dry climate is very desirable. 

ROTHELN. 

History. — From the close of the fifteenth century, at which time Ali 
Abbas described an exanthematous epidemic prevalent in Venice, to the 
present time, it is possible to find evidence of the existence of a conta- 
gious eruptive fever, closely resembling in many respects scarlatina and 
rubeola and often confounded with them, but really distinct from both. 
During the last half of the eighteenth century, the disease was described by 
German physicians under the name of rubeola, while during the same period 
in France and England it was described under the name of roseola, and in 
this country it was called German measles, false measles and rose rash. In 
1874 it prevailed as an epidemic in New York City, and was accurately 
described by Dr. J. Lewis Smith in the Sanitarian for July, 1874. Since 
that time it has made its appearance in man} 7 - places throughout the Mid- 
dle, Southern and Western States. It prevailed quite extensively in 
Charleston, S. C, in the early part of 1880; in Philadelphia and New 
York, in the winter of 1880-81 ; and during the latter period and the 
spring of 1881, it was prevalent in Chicago, and in several places in In- 
diana, Illinois, Michigan, Missouri, and Nebraska. 

Its prevalence in Chicago was well described by Drs. C. W. Earle and 
Roswell Park, in brief papers read to the meeting of the Illinois State 
Medical Society in May, 1881.* 

Causes. — Nothing is known concerning the etiology of this disease, 
except that it appears to prevail most under the same conditions of climate, 
season and sanitary regulations that favor the prevalence of measles and 
scarlatina, and that it is propagated by a specific contagium entirely dis- 
tinct from the contagiums of both the diseases just named. Its independ- 
ent character is proved by the fact that it attacks those who have pre- 
viously had measles and scarlet fever as readily and severely as it does 
those who have never had either. This fact was fully illustrated in the 
cases observed by Dr. Park, as described in the paper already alluded to. 
A large majority of his cases were observed among the inmates of the 
Protestant Orphan Asylum in this city, where, out of 140 children, 95 
were attacked with r5theln, a large proportion of whom had suffered 
attacks of true measles in the same institution only one year previous. 
That age exerts a predisposing influence is shown by the fact that three- 
fourths of all the cases noted have occurred between the ages of two 
and fifteen years. Of 130 cases observed by Emminghaus, only six were 
adults ; of the 95 cases seen by Dr. Park in the asylum, two were adults; 
while of 54 cases seen by J. Lewis Smith, six were adults. 

Symptoms. — After a period of incubation, not very accurately ascertain- 
ed, but of two or three weeks duration, the disease called rotheln commen- 

<See Transactions of the Illinois State Medical Society for 1881, pp. 292-301. 
16 



242 KOSEOLA, 

ces, with very little primary fever; generally one day of slight feelings of 
indisposition, such as moderate headache, sense of weariness, and sensi- 
tiveness to atmospheric changes; and then an efflorescence of red points 
begins to appear on the surface of the neck and upper part of the chest, 
and rapidly extends over most of the cutaneous surface, accompanied by 
some itching or tingling, with slight stuffing of the nostrils and redness 
of the eyes. The pulse is only slightly increased in frequency, and the 
temperature elevated not more than from one to three degrees above 
the natural standard. In some cases there is moderate redness and 
soreness of the fauces, with swelling of the glands in the neck, but 
not in all. The eruption, or rash, is neither papuiar nor vesicular, but 
consists of small red points intermediate between those of measles and scar- 
let fever, being smaller and less clustered in groups than the former, and 
less numerous, with more natural colored skin between them than the lat- 
ter. The eruption and general symptoms usually increase moderately for 
one or two days, and then begin to decline with such rapidity that most 
of the patients may be regarded as convalescent at the end of the first 
week. I have seen a few cases, however, in which the soreness of the 
throat and inflammation of the glands behind and beneath the angles of 
the jaw, were sufficiently severe to protract the sickness until the end of 
the second or even into the third week. 

Prognosis. — From the description I have given, you will infer that the 
disease called rOtheln is a very mild form of exanthematous fever, of short 
duration, and uniformly tending to recovery. I have seen no fatal cases, 
and none followed by important sequelae. Of the one hundred cases re- 
ported on by Dr. R. Park, and the forty mentioned by Dr. Earle, as occur- 
ring under their observation in this city in the winter and spring of 188 J, 
none proved fatal. In a very small number of casas, pneumonia, and gas- 
tric and intestinal irritations have occurred as complications, but not in 
sufficiently severe form to cause a fatal termination. 

Diagnosis. — The only diseases with which r5theln is likely to be con- 
founded are, rubeola, scarlatina and roseola. From the first it is readily 
distinguished by the almost entire absence of premonitory or primary 
fever, and of all bronchial cough or severe catarrhal symptoms; from the 
second, by the absence of primary fever, the very slight disturbance of 
pulse and temperature, and the less uniform diffusion of the rash over the 
whole cutaneous surface; from the third, by the fact that the eruption is 
in the form of small red points, while in roseola the eruption is in red 
spots, varying in size from the circumference of a small pea to that of a 
dime. 

Treatment. — The great majority of cases of rotheln require only rest 
and proper attention to the hygienic conditions connected with the patient. 
A few of the more severe cases may be treated in the same manner as I 
-have advised for scarlatina simplex. 

ROSEOLA. 

Clinical History. — The disease properly called roseola frequently 
occurs simply as a complication of other affections, as gastric derange- 
ments, articular rheumatism, the primary fever of variola and varioloid, 
and as the result of taking certain kinds of food and medicines, as straw- 
berries, shell-fish, balsam copaiba, iodide of potassium, oil of turpentine, 
etc. In these cases it has been styled roseola symptomatica, and requires 
no attention except that which relates to a removal of its cause. The 
disease is also met with occasionally as a mild idiopathic febrile affection, 



PERTUSSIS. 243 

of brief duration and devoid of danger to the patient. It is neither con- 
tagious nor communicable by inoculation, but sometimes prevails as an 
epidemic. The initial stage is usually from one to three days' duration, 
and characterized by moderate dull pains in the head, back and limbs, 
with only a slight increase in the frequency of the pulse or elevation of 
temperature, and but little disturbance of the secretory functions. On 
the second or third day the eruption appears nearly simultaneously on the 
body and extremities, in the form of simple red spots, varying in size 
from two to ten millimeters in diameter, not elevated, and from which the 
redness temporarily disappears on pressure. The color varies in different 
cases from a bright red to a purplish hue. These rose spots are accom- 
panied by only a very slight sense of heat or itching, and they generally 
disappear in two or three days, without leaving desquamation or rough- 
ness, and the patient is convalescent. In a few instances the convales- 
cence is delayed a few days by the eruption appearing in two or three 
successive crops two or three days apart. Careful attention to the brief 
description I have given will enable you to distinguish it from all the oth- 
er eruptive fevers. It is not often accompanied by any important compli- 
cations, neither is it followed by any characteristic sequelae. 

Treatment. — A large majority of the cases require only proper attention 
to the hygienic conditions influencing the patient, but when called to the 
more active class of cases, I have generally directed from four to six grams 
(3i to 3iss) of the bi-tartrate of potassium to be dissolved in a tumblerful 
of cold water, to which a little sugar may be added, and a tablespoonful 
of this solution taken every two or three hours, until the urinary secretion 
becomes free in quantity and the bowels a little relaxed. In malarious 
districts it may be well to give the patient a moderate dose of sulphate of 
quinia once or twice a day during the convalescence. 

] PERTUSSIS. 

Pertussis, or whooping-cough, though not an eruptive fever, is, never- 
theless, a specific, contagious affection, self-limited in duration, and 
attacking chiefly children and youth. It has been recognized and ac- 
curately described from an early period in medical history. Though pre- 
vailing chiefly among children, and occurring but once in the same indi- 
vidual, yet no age is exempt from liability to an attack, and second attacks 
in the same person are occasionally met with. 

Causes. — It is probable that whooping-cough arises solely from a specific 
contagium, generated in the bodies of those affected with the disease, and 
emitted with the breath from the air passages, and, perhaps, with the ex- 
halations from the skin also, during the whole active progress of the 
disease. 

Of the special nature of this contagium we have no satisfactory knowl- 
edge. In 1871, Setzerich claimed to have discovered fungoid germs in 
the epithelium of the air tubes, which he was disposed to regard as the 
specific cause.* Somewhat similar observations have been made by Buhl, 
Oertel, and a few others, but not sufficient to show either the uniformity of 
the presence of such germs from the beginning of the disease, or their caus- 
ative agency when they are present. A large majority of the cases occur 
in children under eight years of age; the susceptibility to the action of 
the contagium apparently diminishing with the advance of age from eight 
years upward. Statistics also show a larger number of attacks in females 

* See Quarterly Journal of Microscopical Science, April, 1871. 



244 PERTUSSIS. 

than in males. It may occur at any season of the year, and in any climate, 
but epidemics have been observed to occur more frequently in the transi- 
tion seasons of the year. 

Symptoms. — After a period of incubation, varying from one to two 
weeks, the initial symptoms develop gradually, and consist of slight gen- 
eral fever, the temperature being from one to three degrees above natural, 
skin dry, face flushed, pulse from ninety to ninety-five per minute ; a sense 
of tightness and soreness in the chest, hoarseness, and a moderate degree 
of cough. In some cases the symptoms commence with chilliness, followed 
by headache, in addition to the other symptoms just named. The aggre- 
gate of symptoms I have named usually increase through the first week, 
at the end of which the general febrile phenomena have reached their 
acme ; the local soreness in the chest and air passages has increased ; and 
the cough has become more frequent, and shows in a more marked degree 
the characteristic feature, which consists in a rapid succession of short, 
quick, spasmodic coughs, without inspiration, until the collapse of the 
chest is complete, when the inspiratory act is caught full, either with or 
without a loud, stridulous sound, called the whoop. No sooner, however, is 
the chest again filled by the inspiration than another succession of rapid 
coughs occur, until the air is exhausted and the face becomes very red, when 
another protracted inspiration re-supplies the exhausted air cells. At this 
stage the paroxysms of coughing usually consist of only one or two series 
of these rapidly repeated acts of coughing, ending in a prolonged inspira- 
tion, with congestion of blood in the face and eyes during the parox- 
ysm. The expectoration is still scanty, tenacious, and difficult to dislodge. 
During the second week the general febrile symptoms remain stationary, 
or rather decline, but the paroxysms of coughing steadily increase in fre- 
quency and severity, until, at the end of the week, each paroxysm consists 
in three or four series of the very rapid, spasmodic hacks or coughs, with the 
rough, stridulous, whooping inspiration between them, until the face be- 
comes turgid and even purple, and the little sufferer appears extremely 
weary. Sometimes, especially in very young children, the severe par- 
oxysms of coughing and strangling end in a reversal of the action of the 
stomach, and free vomiting. 

Yet in a few minutes the fullness and redness of the face subsides, the 
feeling of weariness passes away, and the patient resumes his play and 
cheerfulness until the approach of the next paroxysm. During the third 
week, although there remains no fever and but little derangement of the 
secreting and excreting functions, yet the paroxysms of coughing maintain 
their frequency and full degree of severity, causing the face to look con- 
stantly more or less bloated and puffy around the eyes; the expectoration 
more abundant and opaque or puruloid, and the patient to look weary, 
pale, and somewhat emaciated. With the close of the third week, the dis- 
ease generally begins to decline. 

The paroxysms of coughing become gradually less frequent and 
severe; the appetite begins to improve; the mind is more cheerful; the 
Bleep at night more continuous; and by the end of the fifth or sixth week 
all the characteristic symptoms of the disease have disappeared. When 
left to pursue its own course, the average duration of whooping-cough is 
five or six weeks; but I have seen very mild cases terminate in three, and 
unusually severe ones continue from nine to twelve weeks. While the 
symptoms I have detailed are those which essentially characterize the sev- 
eral stages of the disease, particular cases present additional symptoms 
and complications requiring attention. In some, during the first one or 
two weeks which constitute the febrile stage, the soreness in the chest, 



DIAGNOSIS AND PATHOLOGY. 245 

shortness of breath, and frequency of pulse, are accompanied by a mixture 
of moist and dry rales in one or both sides of the chest, without dullness on 
percussion, and indicate an unusually active bronchitis. When those same 
symptoms are accompanied by a still higher febrile heat, a short expiratory 
act, and some dullness over certain portions of the chest, they indicate 
bronchitis with lobular pneumonia, a dangerous complication, more fre- 
quent in very young children, than in older patients. When the cough 
reaches its greatest severity, which is generally during the third week, the 
protracted repetition of the act of coughing forces the expiratory act to 
such extreme that the circulation is temporarily arrested in the pulmonary 
capillaries, causing fullness of the right cavities of the heart, distension 
of the veins of the neck and face, giving rise, not only to the turgid and 
swollen condition of the face, but in some free bleeding from the nose; in 
others vertigo, with great sense of exhaustion for a few moments after each 
paroxysm; and in a very few, general convulsions. 

The last named accident or complication seldom occurs except in such 
children as are hereditarily predisposed to scrofula or phthisis. I have 
seen a few cases of this class, in which there occurred an occasional con- 
vulsion, and in the fourth and fifth weeks they become pale and much 
worn; the eyes lost their paralellism, they became subject to frequent 
spells of choking, accompanied by spasmodic movements of the eyeballs, 
and when the fontanelles had not fully closed, the head slowly enlarged, 
showing unmistakeable evidence of serous effusion between the pia mater 
and arachnoid membranes. Such cases usually terminate fatally. 

Prognosis. — Very few cases of uncomplicated whooping-cough termi- 
nate fatally. Cases have been reported in which death appeared to re- 
sult from suffocation or direct collapse of the lungs during the violent 
paroxysms of coughing. In other cases the strong determination of 
blood to the head during the coughing has induced such a degree of 
capillary congestion of the brain as to cause speedy death from apo- 
plexy or paralysis. No cases of this kind have come under my observa- 
tion, and I apprehend their occurrence is very rare. Most of the deaths 
attributed to whooping-cough in the bills of mortality are the result of 
capillary bronchitis, pneumonia, or cerebral disease. 

In the summer season, the disease in young children often becomes 
complicated with ilio-colitis or serous diarrhoea, under the influence of 
which they emaciate rapidly and sometimes die from exhaustion. 

Diag?iosis. — During the first or febrile stage of whooping cough, the 
symptoms are so much like those of a sub-acute bronchitis, that it is not 
always easy to make a positive diagnosis. But generally the cough and 
fever, even during this stage, are out of proportion to the physical signs 
of bronchitis. And a little later, when the fever and the physical signs 
of bronchitis are both declining, if the paroxysms of coughing are increasing 
in severity, and assuming more the spasmodic, rapid repetition al character, 
there can be no doubt concerning the true nature of the disease. 

/Special Pathology. — That the contagium or specific cause of the disease 
develops its morbid effects mainly upon the par vagus and pneumogastrie 
nerves, there can be no doubt. And yet there is also a certain degree of 
irritation of the bronchial mucous membrane, so uniformly present as to 
constitute a necessary part of the pathological conditions constituting the 
disease. In some fatal cases, some of the bronchial glands were found en- 
larged, which gave rise to the idea that all the phenomena of the disease 
were caused by the pressure of such enlarged glands on the nerves. But 
there is no proof that such enlargements generally exist in cases of this 
disease, or that when observed they are any more than accidental com- 
plications. 



4o c. c. 


rlSS. 


15 * 


rss. 


60 " 


i»- 


15 grams 


gss. 



246 PERTUSSIS. 

Treatment. — Viewing the disease as an irritation of the nerves just 
mentioned, and of the bronchial mucous membrane, caused by a specific 
poison, for which we know of no reliable antidote, the practical indications 
for treatment are, to lessen, as far as possible, the irritative effects of the 
specific cause on the nervous and membranous structures involved, and to 
prevent the more important complications. During the febrile stage, 
embracing the first one or two weeks, I have long been in the habit of 
using the following combination : 

1^ Syrupus Scilhe Compositi, 
Tincturae Sanguinariae, 
Tincturse Opii Camphoratae, 
Potassii Bromidi, 

Mix. Of this I give to children five years of age, 1.33 cubic centimeters (min. 
xx) every three, four, or six hours, according to the activity of the symp- 
toms, and to adults, four cubic centimeters, or (fl. 3i.) at the same inter- 
vals. Each dose should be mixed with a little additional sweetened wat^r 
when taken. In this mixture we have a mild anodyne expectorant, well 
calculated to allay bronchal irritation, and an efficient sedative to nervous 
excitability. In cases presenting a coated tongue, dry skin, high colored 
urine, with considerable elevation of temperature, I give a single dose of 
thirteen centigrams of calomel (gr. ii.) with two decigrams of sodium bi- 
carbonate (gr. iii.) for a child from four to six years of age, and if it does 
not move the bowels freely in six or eight hours, follow it by some mild 
laxative, and subsequently give a moderate dose of quinine each night and 
morning. After the first two weeks have passed and the paroxyms of 
coughing have assumed their full spasmodic character unaccompanied by 
general fever, I have found no remedies more efficient in lessening the se- 
verity of the paroxyms, and shortening the duration of the disease, than bel- 
ladonna, given in such doses and at such intervals as to keep its effects just 
below that which would dilate the pupils and cause unpleasant dryness of 
the mouth and throat, and one moderate anti-periodic dose of sulphate of 
quinine each morning and evening. A great variety of remedies have 
been recommended, such as chloral hydrate, ammonium, bromide, lobelia. 
musk, camphor, cochineal, nitric acid, nitrite of amyl, and the inhabit. on 
of various anodyne or anti-spasmodic vapors ; and when judiciously 
used, nearly all of them are capable of doing some good. If during all 
the middle and later stages of the disease, you so direct your rem- 
edies as to sustain the tone of the digestive organs, ward off important 
complications, and keep the patient moderately under the influence of 
quinine and such anti-spasmodics as more especially lessen the excita- 
bility of the respiratory system of nerves, you will rarely fail to con-' 
duct your patients to a good and comparatively early convalescence. 
After the first week, or the stage of most fever, the patients should be 
allowed a liberal diet of plain food ; encouraged to go out freely 
in the open air, taking care only that they be so clothed as to protect 
them as well as possible from sudden and severe atmospheric changes; 
but they should never be kept closely confined within doors or shut up 
in over heated- rooms. If complications, such as pneumonia, gastric and 
intestinal irritations, cerebral congestion or convulsions, occur, they must 
be treated on the same principles, and with the same remedies as would 
be appropriate for these several affections under any other circumstances. 
A certain degree of sensitiveness of the stomach, giving rise to ready 
vomiting during the more severe paroxysms of coughing, is present in ma- 



PAROTITIS. 247 

ny cases, especially in young children, and instead of being prejudicial, 
rather cuts short the paroxysms and helps to relieve the patient. 

Sequelae. — The more important affections liable to follow whooping- 
oough are, phthisis, emphysema, chronic capillary bronchitis, scrofulous en- 
largement of the glands of the neck, and hydrocephalus. When these afFec- 
tions become actually devoloped, their management, hygienic and medical, 
must be the same as would be proper under any other circumstances. 

But much can be done during the later stages of the disease and through 
the ordinary period of convalesence to prevent the development of these 
affections if due attention is given at the proper time. It is chiefly in 
children and young persons who are predisposed, by hereditary influences 
or otherwise, to scrofula or tuberculosis that we find the diseases named 
as sequelag of whooping-cough. Consequently, whenever called to pa- 
tients with such predispositions, the practitioner should be on the alert 
and commence as early as practicable to counteract the unfavorable ten- 
dency by tne use of such remedies as the hypophosphites, extract of malt, 
cod-liver oil, a change of air, aud all those hygienic influences that are 
calculated to improve nutrition and the general tone of health. 

MUMPS. 

Parotitis contagiosa, or mumps, is a mild, febrile affection, accompanied 
by a specific or peculiar grade of inflammation of the parotid glands, run- 
ning a definite self-limited course, and dependent for its propagation on a 
contagion generated in the bodies of the sick. Of the nature or form of 
such contagion nothing is definitely known. The disease has often pre- 
vailed in an epidemic form, attacking large numbers in a community with- 
in a limited period of time. The period of life most susceptible to its at- 
tacks is from fifteen to thirty years of age. Males are more susceptible 
than females. Cases have been observed at all periods of life, from in- 
fancy to old age. The disease very rarely attacks the same individual a 
second time. 

The period of incubation between the reception of the poison and the 
commencement of active symptoms, is variously stated, from one to three 
weeks, but I think it is in the great majority of cases between nine and 
fourteen days. 

Symptoms.— The active symptoms are usually ushered in by slight chil- 
liness, followed in a short time by moderate general fever, indicated by 
some pains in the head, back, and limbs; increase of one or two degrees 
in temperature; some increased frequency of pulse; lessening of cuta- 
neous and urinary secretions; and generally slight feeling of soreness or 
stiffness of the parts behind the angle of the jaw. In from twelve to 
twenty-four hours after the commencement of the general symptoms, a dis- 
tinct swelling, accompanied by some pain and tenderness, appears in one 
or both of the parotid regions, caused by an inflammation of the parenchy- 
ma of the gland itself. The swelling and other local symptoms increase 
for two days, when the disease is at its height. The swollen gland stands 
out prominently behind the angle of the jaw, lifting out the lobe of the 
ear and obstructing the opening of the mouth. Deglutition is also more 
or less impeded and often accompanied by sharp pains darting in the di- 
rection of the ears, especially in swallowing acid substances. During the 
third, fourth and fifth days, more or less serous infiltration takes place 
into the areolor tissue, around and below the parotid gland, adding to the 
area of swelling and giving it a semi-cedematious feel, more particularly 
in the sub-maxillary region. By the end of the fourth day the general 



248 PAROTITIS. 

febrile symptoms have usually disappeared, and the decline of the local in- 
flammation and swelling follows with such rapidity that the patient is fully 
convalescent at the end of the week. In some cases the inflammation at- 
tacks only one parotid gland first, and when this has nearly completed its 
course, the other gland becomes involved in the same manner, and the sick- 
ness is thus prolonged through the greater part of the second week. 

In rare instances an inflammation, similar to that of the parotid gland, 
attacks one or both testicles in the male, and the mammary glands and 
ovaries in the female. It is generally supposed that these erratic or mis- 
placed inflammations result from a sudden recession or transference from 
the parotid to the other parts; but in the very few cases that have come 
under my observation, the orchitis supervened, while the inflammation and 
swelling was still progressing in the parotid regions as usual. When the 
testicles are attacked they become painful, very tender to the touch, and 
much swollen, and the general febrile symptoms are much increased. In 
one case, to which I was called about the fifth day after the commence- 
ment of the disease, I found both parotid regions still swollen, hard and 
tender, and both testicles were swollen to three or four times their natural 
size, accompanied by high fever and some delirium. The inflammation of 
the testicles usually increases in intensity during the first three days, re- 
mains stationary one or two days, and then rapidly declines, leaving the 
organs in most instances in their natural condition, but sometimes atro- 
phied and impaired in function. I have not met with a case of mumps in 
which the mammary glands or ovaries were attacked with inflammation; 
and, though such cases are on record, I think they occur very rarely. 
Equally rare is it that the inflammation is transferred to the brain, pro- 
ducing all the symptoms of acute meningitis. 

Diagnosis. — The diagnosis of this disease is not generally difficult. It 
is distinguished from ordinary cases of adenitis or inflammation of the 
glands of the neck, first by the occurrence of distinct general febrile symp- 
toms preceding the local swellings, and second by the location and shape 
of the swelling itself. The swelling in mumps, consisting principally in 
an enlargement of the whole parenchyma of the parotid gland, not only 
bulges out directly behind the ramus of the jaw, but soon somewhat over- 
laps a little the ramus and always lifts out the lobe of the ear. The latter 
is peculiar to swelling of the parotid gland; and, as acute inflammation 
and rapid swelling of this gland is very rare, except when caused by the 
contagion of mumps, it affords a reliable diagnostic mark of that disease. 

Prognosis. — I have never known a case of this disease to terminate 
fatally. Its tendency is uniformly towards recovery, unless it becomes 
complicated with meningitis or inflammation of some other important in- 
ternal organ. It is not often that the disease is followed by important 
sequelae. Atrophy of the testicle sometimes follows the acute stage of 
orchitis, and sometimes, though very rarely, suppuration takes place, 
forming abscesses in the testicles. This last result occurs only in such 
patients as are strongly predisposed to scrofula or tuberculosis. 

Treatment. — In simple uncomplicated cases of mumps, no general med- 
ication is required. Simply remaining within doors to avoid exposure to 
fatigue and cold, as well as to prevent communicating the disease to oth- 
ers, is desirable in all cases. The swollen glands may be bathed often 
with a liniment composed of three parts of camphorated soap liniment and 
one part of tincture of belladonna; if there be much headache and restless- 
ness, a fair dose of bromide of potassium may be given every evening, 
and on the second or third day, if the bowels have not moved, a mild 
saline laxative may be given with advantage. The diet should be light 



CHRONIC GENERAL DISEASES. 249 

and unstimulating during the active progress of the case, but the same as 
ordinary after convalescence commences. This, gentlemen, completes 
the consideration of the very important class of acute general diseases. 
At the next lecture hour I shall commence the discussion of chronic gen- 
eral diseases, better known as constitutional affections. 



LECTUKE XXVII. 

Chronic General Diseases— Diseases included under this head — Circumstances common to them 
all— General Etiological and Pathological considerations concerning them— General Treatment 
etc. 

GENTLEMEN : Having completed the consideration of the acute 
general diseases, I now invite your attention to the second division 
of general diseases called chronic or constitutional affections. Under this 
head belong scrofula, tuberculosis, leucocythaemia, pernicious anasmia, 
Addison's disease, carcinoma, constitutional syphilis, rheumatism and gout. 

Diverse from each other as some of these diseases may appear to be, 
they nevertheless have a sufficient number of circumstances in common 
to justify their being grouped together. 

First. They are all characterized by a very persistent, if not permanent, 
alteration of the natural properties of the tissues, giving rise to certain 
morbid tendencies or predispositions to the development of special local 
affections both of a functional and structural character. 

Second. They are all capable of being transmitted from parent to 
child — in other words, of being perpetuated by hereditary influence. 

Third. So far as relates to the general or constitutional morbid condi- 
tion, there is no tendency to a self-limited duration. 

Fourth. They all arise from causes acting with feeble intensity, but 
persistently, through long periods of time, and of such a nature as to mod- 
ify one or both of the elementary properties of living, organized matter. 

In all these particulars, this group of constitutional diseases stand in di- 
rect contrast with the class of acute general diseases which we have already 
passed in review. You have observed that, in all the latter, the morbid 
manifestations are of an active character, leading rapidly to functional and 
structural changes of limited duration, are incapable of hereditary trans- 
mission, and arise from causes acting with more intensity, but of limited 
duration, one full impression of which often destroys the suscepti- 
bility to any further action of the same cause. On the contrary, the 
diseases I am about to discuss, are based on such changes in the proper- 
ties of the primary organic molecules entering into the various structures 
of the body, as give such molecules certain tendencies to deviate from the 
natural standard or type of development, leading, if not counteracted by 
adverse influences, sooner or later, to such alterations in the molecular 
movements constituting nutrition and disintegration as to develop struct- 
ural changes, consisting of local hypertrophies, atrophies, tissue degener- 
ations, or morbid growths, according to the degree and direction of 
the primary deviations. 



250 CHItOXIC GENERAL DISEASES. 

So slight and occult are the original changes in the properties of the 
organic atoms or cells that the constitutional vice or defect may exist for 
years without any appreciable structural changes,' as we see in those he- 
reditarily predisposed to pulmonary tuberculosis, carcinoma, etc., and yet 
if at any time during the life of such individuals, ordinary exciting causes 
chance to induce local irritation or inflammation, the presence of the latent 
or constitutional condition is made manifest by the unusual persistence of 
the local morbid action and the special tendency to degenerative changes 
in the exudations or other products resulting therefrom. For instance, a 
child possessing the scrofulous diathesis or constitutional condition, if ex- 
posed to a current of cold air upon the neck may have inflammation, exuda- 
tion, and tumefaction of the lymphatic glands, ending either in permanent 
hypertrophy, caseous degeneration, or destructive suppuration; when the 
same cause provoking a similar degree of inflammation in a strictly healthy 
child, would have caused but a temporary exudation and swelling, to be 
followed in a few days by resolution and a return to the natural condition. 
So an adult with the tuberculous diathesis or constitutional condition, at- 
tacked with pneumonia followed by the usual exudation, will be likely to 
have such exuditive material, undergo either purulent degeneration con- 
stituting diffuse suppuration, or caseous degeneration and early phthisis, 
instead of resolution and re-absorption, as usual in subjects previously 
healthy. 

That the primary and essential pathological condition constituting a 
chronic general disease, constitutional vice, cachexia, or diathesis, as it is 
variously called by different authors, consists in a morbid condition of 
one or both of- the inherent properties of organized living matter* 
is proved both by its liability to hereditary transmission, and its 
persistence indefinitely with a well-known tendency to develop, sooner 
or later, specific nutritive changes in some of the structures of 
the body. As the germinal cell or aggregation of bioplasm fur- 
nished by the female, and the spermatozoa furnished by the male, are 
both living organized materials, it is reasonable to suppose that they 
will partake of the same properties, whether perfect or imperfect, that 
belong to all the other organized atoms of the bodies in which 
they were developed ; and consequently in their independent subse- 
quent growth, they will generalh develop the same morbid tendencies 
as were possessed by the parent. The modifications of the properties of 
the germ may be so strong as to lead to manifest errors of nutrition dur- 
ing the development of the foetus in utero, or at any time during the 
period of subsequent growth, or so feeble as not to cause their appear- 
ance until after the climax of adult life in the early stage of physical de- 
cline. While the essential pathology of all this class of diseases consists in 
some modification of the elementary properties that govern the molecular 
changes constituting nutrition and growth, these modifications not only 
differ in degree in different cases in the same constitutional affection, but 
they also differ in kind or direction in each affection from all the others; 
so that the local manifestations of disease developed from time to time 
during the progress of any given case, are peculiar to the special constitu- 
tional affection to which the case belongs. 

For instance, the general morbid condition constituting scrofula, never 
gives rise to the local, functional or structural changes characteristic of 
syphilis, carcinoma, or leucocythaemia and vice versa. Neither do you find 
the rheumatic constitution giving rise to the local inflammations of gout, or 

* See Lecture VI of the present course, pp. 48-9. 



PATHOLOGY. 251 

the reverse. This affords further proof that the primary or fundamental 
pathological condition consists in soma deviation from the natural condi- 
tion of the properties inhering in the organized tissue elements,inasmuch as 
it shows obedience to the universal law of living matter, namely, that like 
begets like, it is true, that constitutional syphilis may be established in a 
subject already scrofulous, or by a sufficient exposure to the proper causes 
and modes of living, gouty affections may be engrafted upon a previously 
rheumatic diathesis; but this in no proper sense invalidates the law just 
stated in regard to the fixed tendencies of each constitutional disease. 
Another fact of much pathological importance is, that the local affections 
which are liable to appear during the unrestrained progress of any one of 
the general diseases included in the class under consideration, are not ac- 
cidental complications, but natural or necessary outgrowths resulting from 
the progress of tne constitutional vice. They may be hastened in their 
appearance, or rendered more severe by the intervention of special excit- 
ing causes, or the influence of bad sanitary conditions. And, on the other 
hand, their development may be retarded or entirely prevented by the 
combined influence of good climatic, hygienic and sanitary regulations. 

And yet, in a large majority of cases, it is the local morbid develop- 
ments that chiefly occupy the attention of the patient, and on account of 
which he seeks the aid of his physician. The local developments resulting 
from the progress of the scrofulous diathesis, appear most frequently in some 
part of the adenoid or lymphatic glandular system, and next in the cutaneous 
surface. Those of the tuberculous, which is colsely allied to, if not a mere 
modification of the scrofulous, may be met with in any of the more vascular 
structures of the body, but are most frequent in the lungs, and next in the 
mucous membranes and lymphatic glands. In leucocythasmia and pseu- 
do-leucocythaemia, the almost uniform tendency is to develop hypertrophy 
or increased growth of the lymphatic glands and spleen. 

Etiology. — There is no doubt but a large proportion of the cases of the 
several diseases included in this group have their origin primarily in heredi- 
tary influence. This I have endeavored to explain already ; but cases are 
also met with in relation to which no hereditary influence can be traced. 
These appear to have had their origin from certain causes which had 
been permitted to act steadily through long periods of time, and yet with 
so moderate a degree of intensity as to avoid exciting acute general dis- 
turbances. One class of these causes produce their deleterious effects by 
acting primarily on the processes of digestion, assimilation and nutrition ; 
another class exert their influence on the processes of disintegration and 
elimination of waste material. To the first, belong insufficient or un whole- 
some food; inadequate supply of light, heat, and pure air and want of 
proper exercise. To the latter, belong all those agents and influences 
that slowly but persistently retard retrograde metamorphosis in the tissues, 
or interfere with the elimination of the products of such metamorphosis 
through the proper excretory organs, such as continued exposure to cold 
and damp air ; deficient physical exercise ; depressing mental emotions ; 
the habitual use of alcoholic drinks ; and the occupation of rooms over- 
crowded, or inadequately supplied with air and sunlight. Food may be 
insufficient in quantity, or in the variety of its nutritive constituents, or 
of such quality as to render it indigestible, and in either case, the blood 
will become more and more defective in the proportion of its nutritive 
elements, and some of the tissues will be correspondingly impoverished. 

There are but few persons in this country who suffer from inability to 
procure a sufficient amount of food. In the feeding and training of chil- 
dren, however, errors of much importance are frequent among all classes. 



252 CHRONIC GENERAL DISEASES. 

Among the poor we often find large families living on the coarser and 
cheaper articles of food, with but little variety from week to week, and at 
the same time occupying damp, uncleanly, and ill-ventilated apartments ; 
and glandular swellings, chronic ophthalmias, caries of the bones, and 
other local evidences of scrofulous and tubercular tendencies are com- 
mon among them. Quite as often among the rich and fashionable we 
find the infants and young children committed to the care of nurses, kept 
much within the limits of the nursery, and indulged so freely in the use of 
saccharine matter, consisting of sugar, candies, sweet-meats, and sweet- 
cakes, at any and all times of the day, that they lose all relish for plain 
bread, milk, meat and other nitrogenous food. The result is that thev 
grow delicate, slender, thin in muscles, with narrow chests, unusual 
mental vivacity, and extreme susceptibility to all kinds of impressions. 
The anxious mothers always assert that they are so delicate they will take 
cold every time they are allowed to go out. It is among the children so 
trained that we find many of the best samples of the scrofulous constitu- 
tional condition, accompanied by frequent temporary, and sometimes per- 
manent, enlargement of the lymphatic glands of the neck. And of those 
belonging to the same class who live beyond childhood and youth, there are 
many who become tuberculous between the ages of eighteen and thirty 
years. 

Nothing is more certainly proved by abundant observation, than the 
fact that long continued living on food deficient in some of the elements 
needed for healthy growth and repair of living structure, is capable of 
modifying the assimilative processes in such a way as to develop imperfect 
cells and other tissue elements. And if to the use of food thus deficient, 
there be added living and sleeping in inadequately ventilated apartments, 
too little habitual exercise of the muscles of the chest and upper extremi- 
ties, and clothing either inadequate for protection against sudden and ex- 
treme atmospheric changes or so adjusted as to impede the free expansion 
of the chest, you have a combination of influences, which, if long continued 
are certain to so modify the properties of the blood and organized tissues 
of the body, as to establish some one of the special diatheses or morbid 
constitutional conditions, whether it be scrofulous, tuberculous, leucocythae- 
mic, or rheumatic. It is also true, that a morbid constitutional condition 
thus acquired, if well established, is capable of being transmitted from pa- 
rent to child, and thus start a new line of hereditary influence. 

A somewhat careful study of the etiology of constitutional diseases, has 
led me to the conclusion that the habits of a people in regard to diet, drinks, 
dress, occupations, and the construction and cleanliness of houses, have far 
more to do with the production and propagation of the scrofulous, tubercu- 
lous, leucocythaemic, cancerous and gouty diatheses, than the elements and 
influences included under the head of climate; while the latter exert a con- 
trolling influence in the formation of the rheumatic predisposition. While 
the protracted influence of low temperature and dampness, combined with 
either impure air or insufficient food, tends strongly to produce the scrofulous 
and tuberculous affections ; a climate characterized by low temperature 
with a high degree of moisture, and accompanied by frequent thermomet- 
ric changes, without other bad influences by habitually interfering with the 
natural exhalations from the cutaneous surface, and consequently retain- 
ing certain acid constituents in excess in the blood, equally tends to 
create the rheumatic diathesis. The excretory material thus re- 
tained evidently acts as an irritant, increasing the susceptibility of the 
fibrous tissues, and the plasticity of the blood, and thus placing the indi- 
vidual in the most favorable condition for the development of active rheu- 



ETIOLOGY. 253 

matic inflammation, with general fever from the temporary action of any 
exciting cause ; or without any such intervention, by long continuance, in- 
ducing those slow hypertrophies and indurations of the fibrous and connect- 
ive tissues, in different parts of the body, that constitute the purely 
chronic rheumatic affections so frequently met with in all cold, damp and 
variable climates. 

The most prominent characteristics of the climate in the whole North- 
ern belt of our own country, from the eastern foot of the Rocky Moun- 
tains to the Atlantic Coast, are long and very variable transition seasons 
(spring and autumn), with a predominance of cold and dampness. And 
it is exactly over this same belt of country that the population furnishes 
the highest ratio of the prevalence of both rheumatic and catarrhal dis- 
eases, as shown many years since in the admirable work on the clim te 
and diseases of the tJnited States, by Dr. Samuel Forrey, formerly of the 
medical staff of the United States Army, and confirmed by the statistics of 
Dr. Daniel Drake, in the first volume of his work on the topography and 
diseases of the great interior valley of this continent. While it is true 
that the rheumatic diathesis is generally the result of habitual reten- 
tion of excretory products capable of increasing the excitability of the 
organized tissues and the plasticity of the blood, such retention is not 
always the result of unfavorable atmospheric or external impressions. 
On the contrary, I have seen numerous instances in which the same patho- 
logical conditions were reached, in some cases by protracted muscular ex- 
ercise by which the products of tissue metamorphosis were developed 
faster than they could be eliminated through the natural channels ; and in 
others, by such changes in habits or occupation that a previous habit of 
active out-d#'or physical exercises sufficient to excite daily increased cu- 
taneous exhalation, was exchanged for one of confinement or purely pas- 
sive exercise, and consequently less activity in the cutaneous surface. 

The gouty constitution or dithesis, like the rheumatic, involves an in- 
crease of susceptibility in the fibrous or connective tissues, but with less 
plasticity of the blood and more tendency to deficiency of the red corpus- 
cles; and the causes most efficient in producing it, are such as directly les- 
sen the action of oxygen in the natural processes of tissue metamorphosis, 
and the evolvement of those products that are eliminated by the kidneys, 
instead of the cutaneous structure. The presence of alcohol in the blood 
lessens the interchange of oxygen and carbonic acid gas through the lungs, 
and retards the molecular changes in the tissues; consequently its moder- 
ate daily use in the form of wine and other fermented drinks, keeps the 
blood in a state of imperfect decarbonization, diminishing the action of 
oxygen on the carbonaceous elements of the tissues, and favoring, first, fat- 
ty accumulations and subsequently, fatty degenerations. If the individual 
thus habitually using, moderately, alcoholic drinks, at the same time in- 
dulges the appetite for animal food, and takes very little muscular exercise, 
he will fail to eliminate the elements of urea, uric acid and the salts of 
sodium through the kidneys sufficiently fast to prevent the blood and tis- 
sues from retaining them in excess. It is the habitual presence of this 
excess of elements naturally excreted by the kidneys, in connection with 
the imperfect oxygenation and decarbonization of the blood, that induces 
those changes in the properties of the tissues which constitute the special 
gouty diathesis; and that every now and then cause the accumulation of 
such an amount of uric acid and urate of sodium as to excite the charac- 
teristic local inflammations of acute and chronic gout. In some instances 
the pathological conditions just mentioned as constituting the gouty 
diathesis, have been produced by habitual indulgence in the use of rich 



254 CHRONIC GENERAL DISEASES. 

food, and the avoidance of all active physical exercise, without the use 
of either fermented or distilled liquors. But such cases are very rare; and 
so far as they have come under my observation there has been reason to 
suspect some degree of hereditary predisposition derived from the more 
remote ancestry. 

Pathological Inferences. — From what I have now said in regard to the 
causes capable of favoring the formation of constitutional diseases and 
their mode of action, you may deduce the following pathological conclu- 
sions : 

First. That all the affections of this class involve as a primary patholog- 
ical condition, such a modification of the properties of the organized 
structures of the body as to render them morbidly susceptible to impres- 
sions and to alter the molecular movements concerned in the processes of 
assimilation, nutrition, and metamorphosis of tissues. 

Second. The modification of properties just mentioned may result from 
hereditary transmission, or from the moderate but long continued action 
of such causes as are capable of either impairing the processes of assimila- 
tion and nutrition; or those of tissue metamorphosis and the execretion of 
waste products. 

Third. In scrofula, tuberculosis, Addison's disease, and pernicious anaemia 
the special modification of tissue properties is such as to increase the sus^ 
ceptibility by which the patients become morbidly sensitive or unduly in- 
fluenced by almost every kind of external impression, and such an im- 
pairment of vital affinity that the formative processes by which the ele- 
ments of tissues are evolved in the blood and attracted to their proper 
places in tissue growth and repair, are rendered imperfect and result in 
the formation of aplastic or cacoplastic material, as found in the. caseous 
and tuberculous deposits and degenerations ; or so greatly impaired as to 
^arrest the formative processes altogether, as in the pernicious anaemia. 

Fourth. In leucocythaemia and carcinoma there is less alteration of the 
susceptibility or excitability, but such an alteration of the vital affinity, or 
force, controlling the formative processes, as to result in an increase of the 
leucocytes and lymphoid cells, leading in the one disease to their marked 
excess in the blood, with hypertrophy of the adenoid glandular structures 
in different parts of the body, and in the other, to a more specific and lo- 
calized cell and fibrous development, constituting the varieties of cancerous 
tumors capable of development chiefly in the dermoid and glandular struct- 
ures containing epithelium. 

Fifth. In rheumatism or gout, the general diathesis or modification of tis- 
sue properties is such as to increase in a marked degree the susceptibility 
or general irritability of the organized structures, and to so modify the mo- 
lecular movements in the metamorphic and excretory processes as to cause 
the retention and consequent accumulation in the blood, of an excess of 
certain excretory products, which, by their action on the already morbidly 
susceptible tissues, are capable of exciting the specific local inflammations 
of rheumatism and gout. In the present status of pathological investiga- 
tions, I may state it as probable that the retained excretory or morbid 
products in rheumatism are chiefly lactic acid, and the lactic acid salts ; 
and in gout, the uric acid and urates. 

Principles of Treatment. — From the statements I have made concern- 
ing the causes and general pathology of the whole class of constitutional 
diseases, you will readily perceive that their practical management involves 
two distinct objects, namely : the removal of the general constitutional vice 
or predisposition, and the treatment of the various local affections that 
may appear from time to time during the progress of each individual case. 



PRINCIPLES OF TREATMENT. 255 

The accomplishment of the first object will depend, mainly, on our ability 
to remove the patient from the further action of those causes and influences 
that favor the development of the particular diathesis in question, and to 
substitute in their place such hygienic and sanitary measures as will bring- 
a strong influence in the opposite direction. As ail these diatheses, when 
not hereditary, are the result of influences acting moderately through long 
periods of time, so they can be removed only by influences acting with 
equal persistence in such direction as to induce an opposite effect. In all 
these affections, so far as the constitutional condition is concerned, a resort 
to active temporary medication of any kind, is both unphilosophical and 
useless. And yet, there are some medicines capable of affording material 
aid to the patient, if properly selected, given in moderate doses and con- 
tinued for a long time. One of the chief difficulties in treating success- 
fully all constitutional diseases and defects, is the inability of the patient 
and his friends to appreciate the necessity for persistence in the use of 
whatever remedial agents or influences are deemed necessary. It seems 
difficult for them, and sometimes even for the physician, tq realize the fact 
that morbid conditions and processes which have been years in developing, 
or may have been inherited, can not be removed or permanently corrected 
by the use of this or that remedy for a few days, or by a vacation from 
school or business, and a change of air, exercise, or climate, for a few 
weeks, or at most, a few months. 

Consequently we see but few well devised and persistently executed 
plans of treatment adopted for either preventing or curing the constitu- 
tional conditions now under consideration. As a general rule, you see 
the children of scrofulous, tuberculous, cancerous, syphilitic, and gouty 
parents, receiving no more attention in regard to their physical training 
than those of healthy parents. Yet, it is during the period of childhood 
and youth, while the structures of the body are undergoing active develop- 
ment, that we have the best, if not the only, opportunity to correct such 
morbid tendencies as result from hereditary influence. And every physi- 
cian should regard it as one of his most important professional duties to 
note the special morbid tendencies of ail the families who rely upon him 
for medical services, and be as careful to point out the means for correct- 
ing them, as he is to prescribe medicines when they are actively sick. 
The family physician should realize that he is the guardian of the health 
of the families by whom he is employed ; and he should so far interest 
himself in the welfare of the children, especiallv, that in his professional 
intercourse he should make such suggestions from time to time regarding 
the physical exercise, diet, dress, and education of the children as may be 
necessary to correct hereditary defects or acquired morbid tendencies 
during the years when such corrections are possible. I can not too 
strongly impress upon each one of you the importance of this subject. 

As the leading pathological or morbid elements of the scrofulous and 
tuberculous diatheses are undue excitability, coincident with impairment 
of vital affinity or formative force, and possibly deficiency of the phos- 
phatic and calcium compounds in the blood, so the remedial measures 
adopted should be such as are most efficient in lessening the former and 
in increasing the two latter. Among the most important of these 
measures is a plentiful supply of dry pure air, at a genial temperature for 
out-door exercise or exposure ; a sufficient quantity and variety of nutri- 
tious and easily digestible food ; clothing of such quality and so 
adjusted as will best protect the cutaneous surface from sudden and 
severe atmospheric changes, and leave all the important movements and 
functions of the body free from mechanical interference ; and such 



256 CHRONIC GENERAL DISEASES. 

habitual daily muscular or physical exercises as tend to increase the develop- 
ment and strength of the muscular structures generally, and especiallv 
those of the chest and upper extremities. 

The heads of all families should be fully advised by their physician of the 
necessity of free ventilation in every part of their dwellings, and especially 
in their sleeping-rooms. Neither children nor adults should be allowed to 
sleep in cellar or basement rooms, or rooms anywhere that do not admit 
of free ventilation and sunlight, and afford, when closed, at least 800 cu- 
bic feet of air space for each person occupying them. The physiological 
law, that regular habitual exercise within certain limits, increases the 
amount and improves the quality of nutrition, is one of primary impor- 
tance, as affording a means for correcting the defects and inequalities of 
development, whether hereditary or acquired, which exist in a large pro- 
portion of all the varieties of constitutional disease. By good air, a fair 
variety of good food, and regular daily exercise, weak and slender muscles 
can be made compact and strong ; narrow chests with deficient air space 
can be made broader and more capacious ; and with a more complete oxy- 
genation and decarbonization of the blood, will come healthier secretory 
actions and more perfect digestion, assimilation and nutrition. Thus, a 
bad constitution, or decided predisposition to disease, can be changed into 
one healthy, and even strong. But it requires much time, judicious di- 
rection, and undeviating steadiness of purpose in the daily execution of 
the work or play directed. And when the morbid conditions or defects 
have become well developed, and the period of growth nearly or quite 
completed, before the systematic work of correction has been commenced, 
it may become necessary to add to the hygienic and sanitary measures al- 
ready alluded to, a change of climate, either temporary or permanent. As 
a general rule, you will find it most beneficial to send those who have 
been habitually living in interior valleys, of moist and alluvial formation, 
either to dry, mild, and elevated mountain ranges, or to the sea shore or 
on sea voyages. 

Those whose chief defects consist in slender muscles, narrow chests, and 
undue sensitiveness of the respiratory organs, will do best in the mild, dry, 
and pure air of the mountains ; while those whose defects are chiefly in 
the functions of the digestive and assimilative organs, will do best in the 
more stimulating and alterant atmosphere of the ocean. And yet those 
who have either inherited or acquired defects while permanently residing 
near the sea, will often be equally benefited by a change either to the in- 
terior valleys or mountains. 

If, in the management of the scrofulous, tuberculous, and kindred 
diatheses, medicinal agents are resorted to, they should be of such a nature 
as to be capable of diminishing the general excitability and of promoting the 
efficiency of the assimilative processes. In other words they should be sooth- 
ing, tonic, and corrective, or mildly alterant. In former times small doses 
of the aqueous solution of iodine, given in some mildly sedative vegetable 
infusion soon after each meal-time, were much used and with good effect. 
The vegetable infusions most used were those of the sarsaparilla, prunus 
virginiana, cimicifuga racemosa, and pipsissewa. During the last fifteen 
or twenty years I have had frequent occasion to recommend for the same 
purposes a combination of two parts of the syrup of iodide of calcium -with 
one part of the fluid extract of humulus lupulus, or hop. To patients over 
fifteen years of age, four cubic centimeters (fl. 3i) of this mixture may be 
given just after each regular meal-time. To younger children the dose 
should be proportionately less. If the patient becomes weary of taking 
this, I substitute the syrup of lacto-phosphate of calcium for two or three 
weeks, after which the other can be resumed. 



PRINCIPLES OF TREATMENT. 257 

But in counteracting the constitutional predispositions now under con- 
sideration, no medicines, however long their use may be continued, can be 
relied upon to the exclusion or neglect of the hygienic and climatic influ- 
ences to which I have referred. 

The diathesis or constitutional condition favoring the development of the 
various forms of cancerous or malignant growths is one of the most obscure 
in the list of chronic general diseases. I am aware that many of the pa- 
thologists and practical surgeons of the present day regard all this class of 
morbid structural developments as primarily local, and claim that the gen- 
eral cachexia or diathesis is secondary, and the result of the diffusion of 
the cancer cells or germs originating in the local affection, But the fact 
that the predisposition to the disease is capable of hereditary transmission, 
while the local development of cancerous structure is often postponed un- 
til after the middle period of life, shows that there must be some devia- 
tion from the strictly healthy condition of the properties that govern the 
combinations of organic matter in the development of tissue elements, 
prior to the first germ of local morbid structure. Again, the fact that in 
a very large majority of cases, cancerous growths re-appear after the ear- 
liest and most complete removal of the first unhealthy structure, points to 
the same conclusion. I have assumed, therefore, that there is a cancerous 
diathesis, or constitutional predisposition which, if not removed, will in 
due time lead to the development of some variety of cancerous structure. 
In a large proportion of cases this diathesis is the result of hereditary in- 
fluence ; but that it may be acquired without such influence is also proved 
by the history of many cases in which no prior existence of this form of 
disease can be traced in either line of ancestry. 

By what circumstances connected with diet, drinks, modes of living, or 
climate, the formation of such a diathesis is favored or counteracted, very 
little is known. In 1866 my colleague in the department of surgery, 
Dr. E. Andrews, by a careful and accurate examination of the mortality 
statistics of this country as returned by the United States census for 
1860, found a much higher ratio of deaths from cancerous diseases in the 
six New England States, and next in New York, Pennsylvania, New 
Jersey and Delaware ; the ratio steadily diminishing as he progressed 
south through the Atlantic States to the peninsula of Florida. The ratio 
was higher in the States occupying the northern part of the interior 
valley of the continent than in those farther south, the lowest ratio of all 
being in the extreme southwest, embracing the States of Texas, Mis- 
souri, Louisiana, Arkansas, and New Mexico. The last named State re- 
turned only one death from cancer to two hundred and seventy from all 
diseases, while Vermont returned one from cancer to forty from all 
diseases. These figures would appear to show that the prevalence of 
cancerous affections was favored by a cold, variable, and damp climate, 
such as that which characterizes the northeastern and northern belt of 
the United States, and to be opposed by one that is mild and dry. 

A more thorough examination of this part of the subject will probably 
demonstrate the proposition that cancerous affections prevail most wher- 
ever a cold and variable climate co-exists with density of population, there- 
by following very nearly the same law of prevalence as scrofula and tu- 
berculosis.* Many facts have come under my own observation favoring 
the idea that a liberal uss of meat coupled with in-door occupations or 
sedentary habits, had a tendency to increase the cancerous predisposition, 

* See Relations of Cancer and Consumption to Climate in the United States. By E. Andrews M. D. 
Chicago Medical Examiner, Vol. VII. p. 737. 18C6. 

17 



258 SCROFULA. 

as it certainly does trie local cancerous growths after they have com- 
menced. In the present state of medical knowledge, perhaps the best 
advice you can give to parties, who, from known hereditary predisposition 
or otherwise, are desirous of counteracting the development of cancerous 
disease in any of the structures of the body, is, that they shall live in a mild, 
dry climate, remote from and elevated above the sea; to take free exercise in 
the open air; to use meat only sparingly; and wholly avoid all use of al- 
coholic drinks and tobacco. The principles that should govern us in the 
management of the rheumatic and gouty diatheses are plainly inferable 
from what I have already said regarding their mode of development: and 
the details of their application will be further explained, when I come to 
speak of the active local developments of these affections. Having com- 
pleted what I deem important to say regarding the general management 
of constitutional diseases, I shall reserve the consideration of the treatment 
necessary after local affections have become apparent, until I call your 
attention to each of the several diseases included in this group separately. 



LECTUEE XXVIII. 



Scrofula— Varieties of Local Development ; Symptoms, Progress and Results ; Special Pathologi- 
'Cal Changes, and Treatment. 

GENTLEMEN : I invite your attention during the present hour, to 
those lojal developments of disease which are connected with, and 
more or less dependent on, the general scrofulous diathesis as described in 
the preceding lecture. 

The local affections, to which I allude, are inflammatory in their char- 
acter, and are most frequently developed in the lymphatic glands, the 
mucous membranes, more especially of the eyes, nose and intestines, the 
skin, and the periosteum. 

Adenitis. — In the ordinary field of general practice, you will meet with 
inflammation and enlargement of the lymphatic glands very frequently, 
especially in children and youth. In a large majority of cases, the gland- 
ular affection is seen only in the neck ; in other cases in the axilla? and 
groin ; and more rarely in other parts of the body. As the scrofulous 
constitution differs much in the degree of its development in different 
cases, so the affections of the lymphatic glands accompanying such consti- 
tutional conditions, vary much in the activity of their development, 
progress and results. For convenience of description, I may include them 
all in three groups. The first group includes all cases of chronic enlarge- 
ment or hypertrophy of the glands from sclerosis of the connective tissue, 
and increase of the lymphoid cells without caseous degeneration. The 
second, such cases as are equally chronic or slow in development, but in 
which the exudation in the central part of the glands undergo caseous 
degeneration and ultimate purulent softening. The third includes cases 
of a more acute character, in which the glands become more rapidly en- 
larged with exudative material that quickly degenerates, forming some 
caseous matter, mixed directly with pus, causing the substance of the 
gland to be early converted into an abscess, which, when discharged, 



DEVELOPMENT. 259 

usually manifests a strong tendency to extend the opening into an ulcer, 
with excavated edges, and but little tendency to fill up with heaithy gran- 
ulations. 

The cases belonging to the first group are met with, most frequently, 
in children between the ages of five and fifteen years, who are delicate 
and usually spare in flesh, but in whom the scrofulous diathesis is only 
moderately developed. In some instances, the first swelling of the giands 
is traceable to exposure to cold, or to an attack of measles, scarlatina, or 
diphtheria, but in a much larger number of cases the glandular affection 
commences without known cause, and without sufficient pain or soreness 
to attract the attention of the patient. They generally appear in the 
form of smooth, firm, round tumors, varying in size from that of a pea to 
a hickory-nut ; very movable under the skin, and without tenderness to 
the touch. They are apt to appear first along the margin of the upper 
third of the sterno-cleido-mastoid muscle, but may be found along any 
part of the side of the neck, from the mastoid process to the outer third 
of the clavicle, or in the groin. 

You may find only one or two in some cases, and in others a dozen or 
more, forming a chain along the whole course of the muscle just named. 
They are distinguished from all forms of malignant growth, by their mod- 
erate firmness or density, smoothness of surface, rounded form, and free 
mobility under the skin. 

A large proportion of these glandular enlargements, after attaining, by 
slow growth, a size varying from that of a large pea to that of a hickory- 
nut, remain nearly stationary for many months, and sometimes years, and 
finally disappear by resolution. 

On the other hand, they are liable at any time, by sudden exposure to 
cold currents of air, or other irritating influences, to become mce actively 
inflamed, tender to the touch, and more swollen, when in many instances 
suppuration ensues, the interior of the gland becomes a simple accumula- 
tion of pus, the free discharge of which is soon followed by cicatrization, 
and a more or less permanent scar. 

Cases of the second group are more frequently developed in persons 
between twelve and twenty years of age. Their beginning is very gen- 
erally traceable to some direct exposure to cold, damp currents of air, to the 
effects of some one of the eruptive fevers, or to an attack of diphtheria. 
There may be only one or many glands involved at the same time ; more 
frequently there are two or more forming a cluster of swollen glands be- 
low the parotid region, and often extending forward below the angle of 
the jaw and backward to the mastoid region. They are generally smooth, 
rounded, and more or less tender to the touch, especially in the early 
stage. After one or two weeks, in many cases, the tenderness to the touch 
disappears, the glands cease to enlarge, and some of the smaller ones be- 
gin slowly to disappear by resolution. The larger ones appear to remain 
stationary for several weeks, or even months, exhibiting a little tender- 
ness, and perhaps increased swelling for a few days at a time, when the 
patient is unduly exposed or suffering from any general febrile disturb- 
ance. Sooner or later, however, you can begin to feel in one or more of 
the more prominent glands, a sense of softening or semi-fluctuation. 

This softening is, in some instances, felt only on the most prominent 
part of the gland, and as though the fluid was not far from the surface, 
while the deeper parts of the gland remain hard, giving it the appearance 
of a small abscess resting on a broad, hard base. A week or two later the 
sense of fluctuation will have become plainer, the skin and subcutaneous 
tissues more adherent to the enlarged gland, but the base is still hard. 



260 SCROFULA. 

If allowed to go on without interference, the matter in the gland will con- 
tinue very slowly to approach the surface ; the skin becomes slightly red 
or purplish color over the most prominent part of the swelling, and event- 
ually from one to four small openings will form, through which the thinner 
part of the matter will discharge. 

Sometimes these openings will gradually enlarge until several unite in 
one large opening with thin, excavated edges, and exposing the bottom or 
base of the gland, generally covered with a layer of white material, with 
no appearance of healthy granulations. In most cases there are little 
masses of caseous material that escape with the thinner pus before the 
abscess becomes converted into an open sore. If proper measures are 
taken to improve the general health, the hard base of these sores gradually 
disappears, the discharge improves in quality and lessens in quantity; 
granulations spring up which are very prone to become large and 
spongy, but cicatrization is eventually completed, and almost always leaves 
a permanently irregular, depressed and unseemly scar. 

The third group of cases to which I have alluded, differ from the second 
chiefly in their more acute character and greater tendency to involve, in 
the suppurative stage, the adjacent areolar or connective tissue and the 
skin. The glands primarily attacked enlarge rapidly, are less movable, 
quite tender to the touch, and present early a blush of redness on the 
surface. If several glands are attacked at the same time, as frequently 
happens, especially in the neck and groin, the pulse will be accelerated 
and the temperature elevated from two to three degrees above the natural 
standard, constituting a moderate general febrile condition. This usually 
oontinues one or two weeks, or until the suppurative stage is completed 
-end the resulting abscesses discharged, either spontaneously or by free in- 
cision. As this group of cases often involves much of the connective 
tissue surrounding the glands, when several are affected near each other, 
the skin becomes extensively undermined by the extent of the suppuration, 
and each opening enlarges into a spreading ulcer with copious purulent 
discharge. It is only a few weeks since I saw a young woman with four 
of these large open ulcers on the upper part of the side of the neck, vary- 
ing in size from twelve to thirty millimeters in diameter, leaving, in some 
places, only narrow strips of skin between them. I have seen other cases 
presenting similar sores along the upper side of the clavicle from its junc- 
tion with the sternum to the acromion process of the scapula, and smaller 
isolated sores in other parts of the body and on the extremities. In all 
these cases the patients were spare in flesh, pale, easily fatigued, with 
variable appetite and imperfect digestion. A small proportion of them 
presented also slight cough and the physical signs of crude, tubercular de- 
posits in the upper part of one or both lungs. But I have not found pul- 
monary tuberculosis a frequent accompaniment of scrofulous disease of 
the lymphatic glandular system. All the forms of disease I have described 
as affecting the lymphatic glands externally, are met with, but less fre- 
quently, in the same class of glands in the internal cavities, and in the 
glands of the mesentery, constituting what the older writers termed " tabes 
mesenterica." I have seen some cases in children in which the abdomen 
became much distended from the enlargement and caseous degeneration of 
the glands of the mesentery. In one of these cases, a boy nearly three years 
of age, two of the enlarged masses became adherent to the anterior walls 
of the abdomen, ulcerated through and discharged a large amount of thin 
pus mixed with many lumps of caseous matter ; but the patient finally 
died from extreme emaciation and exhaustion. More recently 1 saw in 
consultation a young woman, sixteen years of age, whose abdomen had 



PATHOLOGICAL ANATOMY. 261 

become filled up with these large glandular tumors, one of the largest of 
which had gradually softened and finally discharged its contents, composed 
of sero-purulent fluid and curds of caseous matter, into the intestines. 
Only partial or temporary relief followed these discharges, and the patient 
after lingering many months, died. 

Pathological Anatomy. — The pathological changes which take place in 
the adenoid or glandular structures when affected by scrofulous disease, 
are first simple increase of both connective tissue and lymphoid cells, 
causing increased growth or hypertrophy of the glands. 

This is the condition represented by the first group of cases. In the 
second and third groups the same changes occur, but in addition there 
are also formed large cells with many nuclei, called giant cells, and exu- 
dations of granular matter, all of which undergo caseous degeneration, 
and ultimately partial or complete conversion into pus. In many of the 
specimens are found accumulations identical in appearance with the 
structure of tubercle, affording another evidence that there is a very close 
relationship, if not identity, between scrofula and tuberculosis. 

Treatment. — In the management of all the forms and stages of gland- 
ular scrofula, the most careful and persevering attention must be given to 
the improvement of the general constitutional condition or diathesis of the 
patient. Without this, all remedies addressed directly to the local gland- 
ular enlargements will have but little effect. Therefore all that I said in 
the preceding lecture in regard to the hygienic and sanitary measures 
necessary for mitigating or removing the scrofulous and tuberculous dia- 
theses, you must give full heed to, in the treatment of the particular forms 
of disease now under consideration. In addition, however, to the faith- 
ful attention necessary for securing to the patient, good air, good food, 
suitable clothing, sunlight, and well-regulated exercise, as described in 
the preceding lecture, the long-continued internal use of small doses of 
iodine is a measure of much importance. The best form for its adminis- 
tration is the aqueous solution, of which the following is a convenient 
formula : 

1£ Iodini, 0.50 grams, gr. viii 

Potassii Iodidi 2.00 " gr. xxx 

Aquas Distillatse 45.00 c. c. Jiss 

Mix. To patients fifteen years of age and over, 0.60 c. c. (min. x) 
may be given at each meal time, in from one to two tablespoon ful 3 of 
sweetened water. To younger patients the dose should be proportion- 
ately less, but it should always be given largely diluted with water. To 
obtain its full curative influence its use must be continued, with only oc- 
casional interruptions of three or four days at a time, from one to six 
months. If the foregoing treatment is commenced wmile the glands are 
simply enlarged from an increase of the connective tissue and lymphoid 
cells without caseous degeneration, and is continued with the proper hy- 
gienic regulations, in a large majority of the cases the enlargements will 
slowly disappear and the health will be restored. 

But if the central part of the diseased glands has already undergone 
caseous degeneration, and especially if there is an intermixture of tuber- 
culous matter, as in many of the cases that I have described as belonging 
to the second and third groups, it is rare that resolution can be effected 
by any treatment. Even in such cases, however, the treatment judicious- 
ly adjusted will aid in promoting the general health, lessening the extent 
of the suppuration, and rendering the reparative processes more efficient. 



0.06 


grams 


gr. i 


30.00 


c. c. 


fiii 


15.00 


c. c. 


3iv 


15.00 


c. c. 


3iv 



262 SCROFULA. 

Whenever scrofulous glands do suppurate, it is batter to discharge the 
matter by an early incision, than to wait for a spontaneous opening ; inas- 
much as the former is usually followed by a smaller and more regular cica- 
trix than the latter. In some cases attended by extensive suppuration 
and a disposition to the formation of open ulcers with irregular and exca- 
vated edges, I have seen the most satisfactory improvement result from 
the internal use of small doses of the bichloride of mercury dissolved in 
the compound tincture of cinchona, as in the following formula : 

I£ Hydrargyri Chloridi Corrosivi 
Tincturae Cinchona Composite 
Extracti Conii Fluidi 
Syrupus Simplicis \ , 

Mix. Shake the vial and give four cubic centimeters (fl. 3i) to an 
adult, mixed with a tablespooniul of water, and repeat it before breakfast, 
dinner and supper. I have repeatedly seen thoroughly scrofulous patients 
gain in flesh, strength, appetite, and their sores heal, while using this com- 
bination, who had previously taken cod-liver oil, malt, hypophosphites, and 
preparations of iron for several months without improvement. 

It rarely produces any perceptible soreness of the gums or mouth, 
even when its use is continued uninterruptedly for six or eight weeks. 
Like the iodine, the bichloride of mercury is a general alterant, capable of 
so modifying the properties and molecular movements as to counteract 
the tendency to fatty and caseous degenerations, and to increase assimila- 
tion and healthy hsematosis. It is a common practice to apply iodine ex- 
ternally to the swollen glands, either in the form of tincture painted over 
the surface of the swelling, or mixed with camphorated soap liniment, two 
or three parts to one of the tincture of iodine, and applied more freely morn- 
ing and evening. I have seldom soen any marked benefit from these or 
any other external applications in the treatment of scrofulous swellings. 

Applications of the undiluted tincture of iodine soon destroy the 
cuticle, and so inflame the skin as to render the subsequent applications 
very painful. Forth s reason I have generally preferred its dilution with 
camphorated soap liniment sufficient to allow of free wetting of the sur- 
face, morning and evening, without pain. When the texture of a gland 
has began to soften from the formation of pus, if any external applica- 
tions are made, they should be of an emolient character. 

Scrofulous Inflammation of Mucous Membrane, etc.— Children and youth 
of decided scrofulous tendency, are very liable to attacks of inflammation in 
the schneiderian membrane, conjunctiva, the tarsus of the eyelids, the 
cornea, and sometimes the lining of the meatus of the ear. In the latter, 
it sometimes presents the form of impetiginous pustules which soon ma- 
ture, discharge a drop or two of matter, and disappear; or the eruption 
may assume a chronic form, extending by the addition of new pustules 
out upon the tragus and lobe of the ear; the matter in the pustules drying 
into light brown scabs, and giving to the meatus and parts surrounding, a 
sore and untidy appearance, and not unfrequently an offensive odor. In 
other cases, instead of an eruption, the inflammation invades the sub-cuta- 
neous tissue, causing swelling and much pain in the meatus and ending in 
the formation of one or more small abscesses. The pain usually ceases 
with the opening or breaking of the abcess, but in many instances more 
or less purulent discharge continues several weeks. In other cases the 
discharge ceases in three or four days, only to be followed, in one or two 
weeks, by a renewal of the pain and another abscess, until the lit.le 



INFLAMMATION OF MUCUS MEMBRANE. 263 

patients become pale, fretful, restless at night, and very sensitive to at- 
mospheric and all other external impressions. 

The same class of children are much subject to chronic inflammation 
of the membrane lining the nostrils, causiug a purulent and often offensive 
discharge, constituting a form of ozena. In some of these cases erup- 
tions appear on the margins of the anterior nares and the middle section 
of the upper lip, similar to those already described as occurring in the 
meatus and adjacent parts of the ear, giving to the upper lip and wings 
of the nose a sore and swollen appearance. Still more frequently, per- 
haps, you will find the same grades of inflammation attacking the tarsus 
of the eyelids involving both the conjunctival lining of the lids and the 
follicles and glandular structures imbedded in the edge of the tarsus. 
The inflammation may be so slight as to cause only a little thickening of 
the edge of the tarsus, with the escape of a small amount of a gluey ex- 
udation, that dries into hard masses at the root of the eyelashes, and some- 
times causes the edges of the lids to be stuck together on awakening in the 
morning, with slight morbid sensitiveness to light, and the occasional forma- 
tion of a pustule or sty in the edge of the tarsus. If left to its own tend- 
encies, this condition of the eyelids may continue, with but little varia- 
tion, for many months, or even years. In some of the more severe cases, 
all the structures entering into the tarsus of the lids become hypertrophied, 
giving to the edges of the eyelids a thickened and indurated condition, 
with irregular growth of the eyelashes, and sufficient inversion or entropion, 
to bring some of the smaller and less perfect eyelashes in contact with 
the surface of the cornea, with all the symptoms of a foreign body in the 
eye, and the establishment of slow corneitic inflammation and dimin- 
ished transparency. 

In another series of cases, the inflammation attacks primarily the ciliary 
processes and cornea, causing constant photophobia, profuse flow of tears, 
a red zone around some part of the margin of the cornea, composed of 
distended blood-vessels running strictly parallel with each other, and at 
first terminating abruptly at the margin of the cornea, but subsequently 
traceable into or upon the cornea, as if slowly progressing toward a 
common center. 

In most of the cases, at the same time that the red vessels are seen 
entering the cornea, one or more small and superficial ulcers may be 
seen on the surface of the latter, looking like simple indentations. If not 
interfered with by proper treatment, the ulcers slowly extend both in cir- 
cumference and depth, until they perforate all the layers of cornea, and 
allow the delicate membrane lining the anterior chamber of the eye to 
protrude like a hernia through the opening ; and, in some instances, this 
membrane is also perforated, allowing the aqueous humor to escape, with 
partial collapse of the eyeball, adhesions of the iris, and permanent loss of 
vision. In other cases, the ulcers penetrate only through the external 
layer of the cornea, while effusion adds to the aqueous humor, causing the 
weakened cornea to yield to the internal pressure by protruding forward 
and assuming a conical shape, with diminished transparency. In a large 
majority of the cases, however, the ulcers neither penetrate through the 
cornea, nor lead to alterations of its shape, but remain superficial, some- 
times almost disappearing spontaneously with corresponding improvement 
in all the other symptoms, and then increasing again without any appre- 
ciable cause ; thus causing the patients to suffer from more or less photo- 
phobia and inability to use the eyes, either for the purposes of work or 
education, through an indefinite period of time. In former years I have 
seen and treated many of these cases of irritable scrofulous ophthalmia, 



264 SCROFULA. 

in all their grades and stages ; and, among them, it has been not uncom- 
mon to find here and there a child, presenting at one and the samj time, 
the affections I have described, equally developed in the ears, nose and 
eyes. When scrofulous inflammation attacks the cutaneous tissue, it may 
appear in the form of bullae or vesicles of pemphigus, which after breaking 
and discharging the serum or drying up and forming thin scabs, fail to 
cicatrize, and soon present large, superficial and irritable ulcers, with little 
or no disposition to heal. Or, what is more common, is the appearance of 
one or more inflamed places, varying in size from six to eighteen milli- 
meters (one to three-quarters of an inch) in diameter, dark or purplish 
red in color, not acutely painful, but tender to the touch, harder than 
natural, and extending into the subcutaneous tissue, as though there 
might be a tendency to the formation of a small abscess. The hard lump 
or swelling thus formed, usually changes very slowly. 

It neither undergoes resolution nor progresses to the formation of an ab- 
scess, but remains nearly stationary for several weeks, during which the 
skin over the central part of the swelling becomes corrugated, partially 
covered with laminae of cuticle, and finally develops a brown scab, which 
on falling off leaves an open sore. In some cases the ulcer is superficial, 
presenting just enough purulent secretion to favor the formation of a 
scab; in others, its surface is irregular or nodulated, and covered with a 
layer of white lymph, and destitute of granulations. As it progresses, the 
nodules are found to consist largely of caseous material, which disinte- 
grates slowly and sometimes separates in masses, causing the ulcer to be- 
come deeper and larger until the diseased tissue has all disappeared. The 
inflammations I have described, more frequently attack the arms and legs 
and lower part of the neck in the vicinity of the clavicle, or over the upper 
part of the scapula, but may occur on any part of the cutaneous surface. 
I have met with them chiefly among the children of the poor, living in the 
midst of bad sanitary conditions, more especially in damp, uncleanly and 
imperfectly ventilated houses. The only affections with which they are 
liable to be confounded, are those resulting from constitutional syphilis. 
If careful attention is given to the individual and family history of each 
case, together with the fact that nearly all chronic sores and ulcers result- 
ing from constitutional syphilis, present edges of a coppery, instead of 
brownish or livid hue, the diagnosis can be established with reasonable cer- 
tainty. There is but one remaining form of local trouble connected with 
the scrofulous diathesis to which I will direct your attention at this time. 
It is that which affects the periosteum and sometimes leads to caries or 
necrosis of the bones. It is probable that many of the cases of coxaigia 
or hip-joint disease, and of caries and angular curvature of the spine, are 
given their special direction and development by the prior existence of a 
true scrofulous constitutional condition of the patient. 

These, however, are so fully within the domain of surgery, that I shall 
make no further allusion to them here. The cases of scrofulous periostitis 
that will come more directly under the care of the physician, and in which 
an early, correct diagnosis is very important, may be included in two 
groups. The first group embraces such cases as commence in the articu- 
lations, and in which the local inflammation involves coincidently, the 
periostum covering the ends of the bones, the cartilages, and often the 
ligaments with which they are connected. The cases of this kind are 
most frequently seen in the ankle and arch of the foot, the knees, the 
wrists, and the elbows. It generally commences with moderate diffused 
swelling of the part, accompanied by some pain, which is increased by motion 
and pressure, slight increase of heat, but with little or no change of color 



SCROFULOUS PERIOSTITIS. 265 

upon the surface. The swelling, pain and tenderness slowly but persist- 
ently increase, and after several weeks or months, suppuration is estab- 
lished, and whether incisions are made or the matter is allowed to find its 
exit spontaneously, the openings once formed remain fistulous; or, if 
they temporarily close, the pressure of the purulent accumulations cause 
them to re-open, or new ones to form in their place. A careful probing of 
these openings, now, will show that the structures intervening between 
the bony surfaces have been largely destroyed, either by softening and in- 
terstitial absorption or by suppuration, and that more or less of the bony 
surfaces are denuded of their periosteum and rough. In the meantime, the 
patients have become much reduced in flesh and strength, and not unfre- 
quently present all the phenomena of hectic fever, with latent tubercular 
deposits in the lungs or follicles of the intestines, or in both. It is of 
much practical importance to make a correct diagnosis in the first stage of 
all these cases, because the appropriate treatment may arrest their progress 
and prevent those changes which, if allowed to continue, may occasion the 
loss of a limb or the sacrifice of a life. In the early stage many of these 
cases are mistaken for sub-acute rheumatism until suppuration or other 
destructive changes become so far developed as to correct the error. If 
you will give due attention to the fact thai the scrofulous inflammation 
usually commences without any reference to sudden atmospheric changes, 
progresses slowly, and persistently holds its position in the locality where 
it commences, while sub-acute rheumatism is always markedly influenced 
by atmospheric conditions, is migratory or moving from one articulation 
to another, and very rarely fails to attack several localities, either simul- 
taneously or in regular succession, you will seldom mistake one of these 
affections for the other. In the second group of cases of scrofulous peri- 
ostitis the disease commences on some part of the body or shaft of the 
bone, and is most frequently seen on the phalanges of the fingers, the ulna, 
the clavicle, the sternum, and the long bones of the lower extremities. It 
is manifested, first, by a diffused swelling or thickening of the periosteum, 
usually with only a dull pain and moderate tenderness to pressure, but 
neither redness nor heat. If not interfered with by treatment, the swell- 
ing slowly increases and extends more around the circumference of the 
bone, the surface shows a more dull red or purplish color and more tender 
to the touch. After several weeks of very slow progress, some one or two 
places become more prominent and present a semi-fluctuating feeling; the 
skin at these points is deeper or more livid red and more sensitive to 
pressure. If a free incision is made, it generally gives exit to a small 
amount of pus, and is not followed by any considerable diminution of the 
swelling, but remains open and often enlarges into a deep, ill-conditioned 
ulcer, sometimes from sloughing, and other times from simple disintegration 
of the tissues. If an incision is not made, one or more small openings 
eventually form, giving exit to a small quantity of thin pus or sero-purulent 
fluid, after which they extend in the same manner as in case of an incision. 
In some cases, several of these openings form over the surface of the 
same bone. Sometimes the periosteum is destroyed, and the naked, rough 
surface of the bone may be seen or touched with a probe at the bottom of 
the sores. In one girl, about seven years of age, there were three deep, 
indolent sores on the side of the neck, in place of destroyed lymphatic 
glands, two over the surface of the clavicle, and one over the upper seg- 
ment of the sternum. Several years since, a boy about five years of age 
came under my observation, who had nearly all the phalanges of his fingers 
attacked at different times with scrofulous periostitis. In three fingers of 
one hand, and two of the other, the periosteal inflammation gradually ex- 



2GG LOCAL SCROFULA. 

tended over the whole length of the middle phalange, separating and de- 
stroying it to such a degree as to cause necrosis of the whole bone, neces- 
sitating its removal, and leaving each finger much shortened and its use- 
fulness impaired. Yet he subsequently recovered fair health. In many 
of this class of cases you may find some difficulty in maintaining a def- 
inite line of distinction between them and the periosteal inflammations 
dependent on constitutional syphilis. The latter usually occur in adult 
life, are much the more frequently connected with the tibia, bones of the 
cranium, nose and ulna, and suppurate slowly, leading to caries of the 
bones and fistulous openings, but seldom to large open sores. The scrof- 
ulous affection is manifested chiefly in children under fifteen years of 
age — more frequently attacks the fingers, clavicle, sternum, and parts en- 
tering into the articulations, suppurates more readily, and in doing so, in- 
volves to a greater extent all the soft tissues lying over the seat of disease. 
These facts, with strict attention to the history of the patient and his he- 
reditary predisposition, will enable you to make a correct diagnosis in all 
ordinary cases. It has been claimed by some members of the profession, 
of great eminence, however, that all the forms of scrofula are only the more 
remote manifestations of constitutional and hereditary syphilis.* 

Treatment. — The same principles of treatment, both hygienic and medi- 
cal, are applicable in the management of the scrofulous affections of mu- 
cous membranes, skin, periosteum, etc., as I have already explained to you 
in speaking of the treatment of glandular scrofula. The same careful 
attention to good air, appropriate food, and such exercise as the patient 
will bear, is essential to the success of any plan of treatment that may be 
devised; and in most cases, a limited and judicious use of iodine or the 
bichloride of mercurj', or both alternately, as general alterants, will be 
found necessary. In almust all cases they should be given coincidently 
with the preparations of peruvian bark or other bitter tonics. In the 
scrofulous ophthalmia of children, characterized by irritable ulcerations of 
the cornea and great photophobia, I have found no other treatment so 
certain to arrest the progress of the disease and ultimately restore the pa- 
tient to health, as the use of the formula I have given you containing the 
bichloride of mercury, compound tincture of cinchona, etc., in doses suited 
to the age of the patient, with only very mild anodyne applications exter- 
nally, or none at all. In all of this class of cases the eyes should be shaded 
from the direct rays of light, but should not be closely covered nor the 
patient confined to a dark room. In nearly all the cases of indolent, non- 
granulating scrofulous ulcers in the skin, and in the periosteal affections I 
have described, I have succeeded best by giving the formula containing the 
bichloride of mercury for the first two weeks of the treatment and then 
substituting the iodine. You may be ready to ask why I do not use the 
combinations of mercury and iodine, in the forms of proto or bin-iodides, 
in these cases. My answer is, that simple clinical experience has shown 
me that I do not get the same good effects from them, while they are much 
more liable to disturb the stomach or bowels. Neither have I ever ob- 
tained any perceptible good effects from the internal administration of 
the iodides of potassium, sodium and ammonium, in true scrofulous affec- 
tions. On the contrary, if given in the usual liberal doses, they soon be- 
gin to impair the appetite, lessen the activity of nutrition, and create in- 
creased feelings of weakness, with no improvement in the local affections. 
This constitutes a marked distinction between the effects of remedies in 
the treatment of true scrofula and constitutional syphilis. 

*See Address on Surgery, by S. D. Gross, M. D., LLD., etc. Transactions of the American Medical 
Association, Vol. 25, p. 219 to 292—1874. 



TREATMENT. 267 

Local Applications. — In all the forms of scrofulous ulcers, except those in 
the cornea orother parts of the eye-ball, slightly stimulating and antiseptic 
applications once or twice a day will generally do some good. Weak solu- 
tions of iodine, permanganate of potassium, carbolic acid, and benzoic, 
acid, are among the best. They may be applied morning and evening 
and the sores covered in the interval with lint smeared with cosmoline or 
vaseline. In those cases of purely chronic inflammation and thickening of 
the tarsus of the eyelids, with the exudation of a gummy substance, 
causing the lids to adhere to each other in the morning, I have obtained 
much benefit from the application of the following salve : 

1)6 Hydrargyri Oxidi Rubri 1 gram gr. xv. 

Powder finely and add 
Cerati Simplicis 30 grams |i. 

Mix thoroughly, and apply a little to the edges of the eyelids just be- 
fore going to bed each night. 

Care must be exercised to have the salve accurately applied simply to the 
margin, and not to the inner surface of the lids. Very much more might 
be said in regard to the use of remedies in the treatment of the various 
local affections connected with the scrofulous diathesis ; but I have given 
you the results of a long and ample experience, during which I have tried 
almost every variety of treatment hitherto proposed in this troublesome 
class of affections, and I am satisfied that the suggestions I have made, if 
judiciously applied, will give you the best results attainable in the present 
state of medical science. 



LECTUKE XXIX. 

Leucocythseniia. Pseudo-Leucocythsemia, Pernicious Anaemia and Addison's Disease— Their His- 
tory, Causes, Symptoms, Special Pathology, Diagnosis, Prognosis and Treatment. 

GENTLEMEN: — If I were to follow strictly the order given in my enu- 
meration of the diseases included in the class now under consideration, 
1 should next consider the local developments of tuberculosis. But such 
of these developments as are not intimately connected with the local 
scrofulous affections considered during the preceding lecture hour, are so 
uniformly connected with the lungs, constituting a form of pulmonary 
phthisis, or with the membranes of the brain leading to a form of menin- 
gitis, that I shall consider them in connection with the other local affec- 
tions of the respiratory organs and membranes of the brain. I do this 
chiefly because a proper study of their diagnosis involves a close compar- 
ison between them and the d.fferent grades of inflammation in the same 
structures. Passing by the local manifestations of tuberculosis for the 
present, I shall now consider briefly the diseases recently named Leuco- 
cythaemia, pseudo-leucocythasmia, etc. These names have been used to 
designate forms of disease very closely related to each other, and to the 
adenoid or glandular form of scrofula. Indeed, until a comparatively 



268 LEUCOCYTHAEMIA. 

recent period, the cases included under those heads were generally regarded 
as only different forms of scrofula. In 1845, Dr. Hughes Bennett first called 
attention to the fact that a certain group of cases were uniformly charac- 
terized by a large excess of white corpuscles in the blood, coupled with 
hypertrophy or hyperplasia of the spleen, and a large number of the lym- 
phatic glands in different parts of the body; and he gave to them the 
name of leucocythaemia. About the same time Virchow described a 
similar group of cases and called the disease leukaemia, or leucaemia, mean- 
ing white blood. Both identified and described the same form of disease, 
but the name chosen by Bennett, meaning excess of white corpuscles in- 
stead of white blood, is the most appropriate. Although never differenti- 
ated from other forms of anaemia and scrofula until done by Bennett and 
Virchow in 1845, yet the disease now called leucocythaemia has occurred 
in all civilized countries from an early period of medical history. Its pos- 
itive and accurate diagnosis could not be established, however, until the 
application of the microscope to the stud}' of minute anatomy had become 
familiar to the profession. The names chosen by Bennett and Virchow 
are suggested solely by the altered condition of the blood. But the 
spleen and lymphatic glandular structures are apparently as constantly 
and extensively altered from their natural condition as is the blood. 
Hence Trousseau calls the disease adenie; Gresinger, anaemia splenica; 
Jaccoud, a lymphagenic diathesis; and others have used the terms 
anaemia lymphatica; splenic leucocythaemia; medullo-splenic disease, etc* 

Causes. — The essential causes of leucocythaemia are so obscure as to 
have, thus far, eluded observation. Literally, nothing is known concern- 
ing the etiology of the disease. It occurs most frequently during the 
active period of adult life, from twenty to forty years of age. But cases 
have been observed at all stages of life, from childhood to old age. It 
has beer seen much more frequently in the male than in the female sex. 
It has beer claimed that excessive mental and physical labor, and the oc- 
cupation of damp and poorly ventilated dwellings, acted as predisposing 
causes. If they do so, it is probably only by lessening the general tone 
of health, and thereby impairing the resistance to all morbid impres- 
sions. 

Symptoms. — The early symptoms of the disease are very obscure and 
ill-defined. They consist chiefly in diminished power of endurance, or 
unusual weariness, from either mental or physical exercise, variable 
appetite, with slight impairment of digestion, imperfect or disturbed 
sleep, nervous excitement and increased cardiac action from slight causes, 
and a gradually increasing paleness or anaemic hue of the surface. These 
equivocal and variable symptoms may be noticeable for several months 
before . the development of any swelling or enlargement, either in the 
spleen or lymphatic glands. Generally, however, in from six to twelve 
months, the patient begins to present a decidedly anaemic look, and finds 
so much shortness of breath, palpitation, and sense of weariness from 
very moderate attempts to exercise, that he is obliged to abandon all active 
business. He now has frequent temporary paroxysms of fever, with dis- 
order of the stomach and bowels, wandering pains in his head, back, limbs 
— sometimes vertigo, with dimness of vision, and the urinary secretion is 
very variable in quantity, being sometimes abundant and pale — at other 
times less than natural, and deeper color, but without the presence 
of either albumen or sugar. A careful examination of the patient will now 
detect plain anaemic or soft blowing sounds over the base of the heart and 
in the course of the aorta, with habitual frequency and softness of the 
pulse; but no physical signs of structural change, either in the heart or 



MOPvBID ANATOMY. 2G9 

luno-s. In a majority of cases there will be unnatural fullness of the left 
bypochondrae region, which can be traced by palpation and percussion, to 
enlargement of the spleen. In a large proportion of the cases, at this stage, 
there are found enlargements of the lymphatic glands in the groins, often 
extending in a chain up the course of the iliac vessels, into the abdomen; 
and in some cases the same class of glands are enlarged, both in the axilla 
and neck. From this time or stage in the development of the disease, 
the health of the patient fails more rapidly. The anaemia, glandular 
swellings, shortness of breath, and palpitations from slight exertion, all 
steadily increase. The glandular swellings are generally rounded, freely 
movable, less hard or dense than the glandular enlargements in scrofula, 
and varying in size from that of a pea to a hen's egg. The spleen usu- 
allv continues to increase, until it sometimes fills the whole left side of the 
abdomen, and, except the natural indentations along the edge, its surface 
is smooth and but little tender to the touch. In some cases, the liver also 
becomes enlarged, especially in the advanced stage of the disease. The 
patient has more frequent attacks of diarrhoea or vomiting, and sometimes 
both. Haemorrhages, especially from the nostrils, and in some cases from 
the gums, bowels, uterus, and kidneys, are of frequent occurrence. 
Petechial spots appear on the surface, and sometimes considerable extra- 
vasations of blood take place into the subcutaneous areolar tissue. In 
some instances, death takes place suddenly from extravasation of blood 
into some part of the brain. More frequently death results from serous 
or dropsical effusions, not only into the areolar tissues and serous cavities, 
but into the parenchyma of the lungs and other organs, or from persistent 
diarrhoea. Some, however, linger long, and die from asthenia, or simple 
exhaustion. Cases differ much in the rapidity of their progress. Some 
reach a fatal result in five or six months, while others continue as many 
years. The average duration, as indicated by such cases as have been col- 
lated by different writers, is about two years. 

Morbid Anatomy. — Post mortem examinations have revealed important 
changes resulting from the progress of this disease, both in the blood and in 
several of the structures of the body. The most important and characteristic 
change in the blood, consists of a large increase in the number of white 
corpuscles or leucocytes, and a corresponding diminution of the red blood 
discs. So great is this change that in some cases the number of white cor- 
puscles actually exceeds those of the red. In the great majority of cases, 
however, the relative proportion varies from one of the white, to ten, fif- 
teen, or twenty of the red corpuscles. Notwithstanding the great increase 
of the white corpuscles, the decrease of the red ones is relatively still 
greater; thereby causing the aggregate of corpuscular elements in the blood 
to be much less than in health. 

The greater number of white corpuscles appear of their natural size, but 
some are smaller, and a few are found much larger and filled with nuclei 
or granular matter, much like the ordinary giant cells of the lymphoid tis- 
sues. These changes make the blood look much paler than natural; and 
the clots that form to be of a light yellowish color and small; but the pro- 
portion of fibrine is moderately increased. 

The composition of the secretions generally does not differ in a marked 
degree from that of health. The urine generally contains an excess of uric 
aeid; and in a small proportion of cases, traces of formic and lactic acids and 
hypoxanthin have been found. These same substances, together with 
leucin, tyrosin, and minute, colorless octohedral crystals, first described by 
Charcot, have been detected in the blood in some instances. But their 
presence is not constant either in the blood or urine; neither are they pe- 



2 70 LEUCOCYTH.EMI A . 

culiar to this disease. Next to the blood, the most marked and constant 
changes are found in the spleen, lymphatic glands, and medulla or marrow 
of the bones. These changes are quite uniform in kind but differing much 
in degree in different cases. They consist of an increase of the lymphoid 
cells and reticulated tissue and consequent enlargement or hypertrophy of 
the glandular structures without material alteration of constituents; but 
the marrow of the bones being inclosed in such a way as to prevent en- 
largement, the increase of lymphoid cells causes the disappearance of the 
natural fatty matter, and gives to the medulla a reddish or greenish yellow 
color and creamy consistence. It is chiefly in the medulla or marrow of 
the long bones of the extremities, and of the ribs and vertebrae, that these 
changes have been observed. The excess of lymphoid cells in all these 
structures vary much in size, some being smaller and others larger than 
natural. As a rule, the smaller ones predominate in the lymphatic glands, 
and the larger nucleated and granular cells are more numerous in the me- 
dulla of the bones and in the pulp of the spleen. The changes and lym- 
phoid cell accumulations are not limited entirely to the spleen, lymphatic 
glands, and medulla of the bones, but in very many cases are found to have 
occurred in a less degree, in the lobules of the liver, the kidneys, the gland- 
ular structures of the mucous membrane of the alimentary canal, the brain, 
the retina of the eye, and the testicles. These structural changes are not 
found equally developed in all the structures involved in each case. For 
instance, in many cases they will be very prominent in the spleen, and 
comparatively slight in all other parts. These have been called splenic- 
leucocythaemia. In other cases, the lymphatic glands generally have be- 
come prominently affected with hyperplasia, while the spleen is only slight- 
ly altered. These have been called lymphatic-leucocythaemia. In a smaller 
number of cases the changes have chiefly occurred in the medulla of the 
bones, with but little in either the sp'een or lymphatic glands; and these 
haye been called medulla-leucocythaemia.* 

Special Pathology. — The nature of the primary morbid actions from which 
result the progressive and persistent alterations in the blood and struct- 
ures, such as I have just described, are involved in obscurity, on account 
of our imperfect knowledge of the physiological processes by which the 
corpuscular elements of the blood are formed in health. That white cor- 
puscles appear in the chyle during and after its passage through the mes- 
enteric glands, and in the lymphatic vessels that take up the colorless 
fluids from the several tissues of the body, and that such corpuscles are in- 
creased during the passage of this fluid through the lymphatic glands, 
are facts familiar to all of you. But how and where the red corpuscles are 
formed is still undetermined. For a long time they were supposed to be 
formed in the spleen. More recently several observers have discovered 
these bodies in what appeared to be different stages of formation in the 
medulla or marrow of the bones; and consequently have regarded this as 
the seat of their formation. This view was thought to be corroborated by 
the fact that the marrow of the bones was found to have undergone marked 
changes of structure in many of the cases of leucocythaemia. If post 
mortem examinations had shown a constant correspondence between the. 
changes in the bone marrow and the degree of diminution of red corpuscles, 
the evidence would have been of much value. But such is not the fact. 
On the contrary, in many cases of extreme leucocythaemic anaemia, very 
little change has been observed in the marrow of the bones; and in a few, 
none that was appreciable. 

* See Nauman, in Berlin Klin. Wochensehrift, No. 6, 1878. 



DIAGNOSIS. 271 

My own observations have led me to think that there are two kinds of 
white corpuscles, both formed as a part of the assimilative changes which 
take place in the reticulated tissue or lymphatic vessels and glands. One 
kind constitute the true migrating corpuscles that accumulate so readily in 
the vessels of inflamed parts, permeate freely the walls of capillary ves- 
sels, and enter directly into the nutrition of the various organized struct- 
ures. The other kind have less ameboid movement, often attain a larger 
size and look more granular, and somewhere in their progress, they become 
permeated with the haemoglobin and are transformed into red corpuscles. 
^Vhether this latter change is completed while they are passing through 
the marrow of the bones, the pulp and malpighian vessels of the spleen, or 
while floating in the mass of the blood, cannot be positively determined in 
the present state of physiological science. Be this as it may, however, I 
am satisfied that the first and essential step in the pathology of leucocythae- 
mia consists in the failure to complete the transformation of white into red 
corpuscles. Whether this results from some imperfection in the properties 
of the white corpuscles by which they fail to attract the haemoglobin; or 
whether the latter is itself deficient, cannot be readily determined. The 
failure to complete the conversion of the white corpuscles into the red, al- 
lows the former to accumulate in the blood and in the adenoid or reticulat- 
ed tissues, causing slow hypertrophy of some part or all of the latter, as 
seen in the ultimate enlargements of the spleen, lymphatic glands, mar- 
row of the bones, etc. At the same time, as new red corpuscles cease to 
develop, and those already existing slowly disappear, the resulting im- 
poverishment brings steadily increasing paleness, muscular weakness, in- 
capacity for active exertion, shortness of breath, palpitations, and general 
functional derangements. 

That the diminution of the red corpuscles is the result of failure in some 
part of the processes by which they are developed, and not from an in- 
crease in the rapidity of their destruction, is evident, from the fact that at 
no stage of the disease do we find an increase of the products of such de- 
struction in the form of dark granules or melanotic deposits, such as appear 
so abundant when they are undergoing increased destruction from malari- 
ous influence. 

Diagnosis. — In its early stage, leucocythae'nia is liable to be confounded 
with various other spanaemic conditions of the blood, and impairments of 
nutrition; such as scrofula, chlorosis, pernicious anaemia, etc. From all 
these, however, it is distinguished with much certainty by the presence of 
an increased number of white corpuscles, and a corresponding diminution 
of the red, as shown on the field of the microscope. As the relative pro- 
portion of both red and white corpuscles, varies much in different indi- 
viduals and in different morbid conditions, it becomes desirable to deter- 
mine the degree of change that shall be regarded as certainly indicating 
the presence of the disease under consideration. If a proper examination 
of the blood shows the presence of one white to twenty red corpuscles, 
most writers regard it as sufficient evidence of the presence of leucocy- 
thaemia. 

But the ratio of the white to the red corpuscles in healthy blood, does 
not exceed one in from five hundred to one thousand; and if you have a 
patient with the early general symptoms of leucocythaemia, and on exam- 
ining the blood you find one white to fifty red globules, and at two or 
three subsequent examinations at intervals of one or two weeks, you find 
a progressive ratio of increase in the number of white ones, you will be 
safe in regarding the diagnosis as established. For the steadily increas- 
ing ratio of the one relatively to the other, through a given period of 



272 LEUCOCYTHiEMIA. 

time, is quite as important in a diagnostic point of view, as any arbitrary 
standard of such ratio. 

Prognosis. — Whatever may be the nature of the morbid condition by 
which the white corpuscles are prevented from further development into 
red ones, when once established, it usually persists in opposition to all 
efforts hitherto made for remedying it, until the life of the patient is de- 
stroyed. The most obvious fault, is the failure in the production of 
haemoglobin and its union with the other elements of the colored corpus- 
cles. But no methods of treatment have yet been successful in remedy- 
ing this defect, or in materially modifying the progress of the disease. 
Consequently, the prognosis in well marked cases of leucocythaemia must 
be regarded as uniformly unfavorable. 

Treatment. — Seeing the pallor and general weakness of the patient, 
you will naturally turn with some confidence to the use of fresh air, good 
food and ferruginous tonics, as in other forms of anaemia, with the expecta- 
tion of improving the nutritive processes and checking the progressive 
impoverishment of the blood. At the same time the enlarged spleen and 
lymphatic glands will suggest the use of iodine, quinine, arsenic, and 
other alteratives. But, gentlemen, all these remedies, and many more, 
aided by change of air and climate, have been perseveringly used, with- 
out obtaining any permanent control over the progress of the disease. 
Those who regard the disease as having its origin in the spleen, have re- 
sorted to a liberal use of quinine, ergotine, iron, iodine, mercurial inunction 
and electricity, with the hope of reducing the size of that organ, and 
thereby arresting the further involvement of the system generally. Find- 
ing remedies unavailing, the spleen has been extirpated in several cases, 
but with uniformly fatal results, either from haemorrhage or peritonitis. 
Remedies addressed to the lymphatic glandular enlargements have been 
attended by no better results. In the present state of knowledge on this 
subject, I can give you no better advice, than to examine carefully the 
sanitary history, habits and surroundings of your patient, with a view to 
the detection and removal of all influences that could affect unfavorably, 
either the assimilative or excretory functions, or the healthful tone of 
the nervous system. Let the sleeping room be of good size, dry, well 
lighted and well ventilated. Let the diet be plain, easily digestibie, and 
embracing sufficient variety for supplying all the elements necessary for 
perfect haematosis and nutrition. Let the exercise be habitually in the 
open air, by riding or walking, as best suits the strength and comfort of 
the patient; and after every ride or walk, let there be at least half an hour 
of full rest in the recumbent position. If the patient has long resided in 
the interior and has the means for traveling, let him visit, and tarry 
during the warm months at the seaside. If his residence is near the 
sea, let him change to the mountains; or if on a damp and malarious 
soil, let him move permanently to one moderately elevated and dry. So 
far as possible, let the social surroundings of the patient be such as to 
promote mental cheerfulness and hope. All these items are worthy of 
the most careful attention, especially in the earlier stages of the dis- 
ease. 

For direct medication I should rely much upon the tonic and alterant in- 
fluences of the following formulae : 

]£ Hydrargyri Chloridi Corosivi 0.066 grams gr. L 

Tincturae Cinchonae Compositae 90.000 c. c. Jiii 
Elixir Simplicis 30.000 " " |i 

Mix. Give four cubic centimeters, (fl 3i) in a little water just before 



PSEUDOLEUC0CYTH.EMIA. 273 

breakfast, dinner and supper. To supply materials for the haemoglobin I 
give half an hour after each meal, an ordinary dose, of either the syrup of 
lacto-phosphate of iron, the pyrophosphate of iron, or the compound syrup 
of the hypophosphites. . One of these may be given until the patient be- 
comes weary of the same impression and then exchanged for another. And 
to lessen the danger of inducing any effect of the mercurial on the mouth 
or salivary glands, the bichloride may be omitted from the formula I just 
gave, during every third week. 

Another measure worthy of persevering use, is the application of elec- 
tricity. This should be done, sometimes by insulating the patient and 
charging the system moderately, and more frequently by giving the pa- 
tient the positive pole in one hand, the operator taking the negative in one 
of his, and then making the connection by frictions with the other over the 
spleen and the various lymphatic glandular enlargements. To obtain the 
maximum of influence, the applications should be continued from ten to 
twenty minutes once each day. Such is the general course of management 
which I have found most beneficial in the limited number of cases that 
have come under my own observation. Of course due attention must be 
given to the palliation of some of the more distressing symptoms as they 
occur. Hemorrhages, diarrhceal attacks, palpitations, etc., must be tem- 
porarily met by appropriate remedies; and in malarious districts the judi- 
cious use of quinine, either alone, or in combination with iron and strychnia 
may be of great advantage. 

PSEUDO-LEUCOCYTH^MIA. 

Very closely allied to the disease I have just considered, if indeed it be 
not a mere variety of the same, is the pseudo or false leucocythaemia of 
recent writers. It was first described as a distinct disease, and differenti- 
ated from ordinary scrofulous affections by Dr. Hodgkin in 1832. 

His descriptions, however, included all cases in which there were as- 
sociated special enlargement of the spleen, with more or less hypertrophy 
of the lymphatic glands. It w T as not until thirteen years later, that Ben- 
nett and Virchow separated the cases characterized by excess of white cor- 
puscles in the blood from those having no such excess, and gave to the first 
the name of leucocythaemia or leukaemia, and leaving the latter to be 
called pseudo-leucocythaemia or Hodgkin's disease. The clinical his- 
tory, or symptoms and progress, of the two diseases, present no constant or 
essential differences. In the pseudo-leucocythaemic form of disease, 3^011 
have the same obscure beginning, and subsequently the same progressive 
anaemia or impoverishment of the red corpuscles of the blood, loss of 
strength, shortness of breath, palpitations, and hypertrophies of the spleen 
and lymphatic glands; and in the advanced stage, haemorrhages, diarrhoeas, 
dropsical effusions, etc.; and the same persistent tendency to a fatal result. 
The only positive condition on which a differential diagnosis can be based, 
is the want of a sufficient number of white corpuscles in the blood to 
come within the rule adopted as necessary to constitute true leucocythae- 
mia. In a majority of the cases classed as Hodgkin's disease there is more 
extensive hypertrophy of the lymphatic glands and reticulated or adenoid 
tissues throughout the system, except in the medulla of the bones; which 
latter, however, has not yet received as much attention as Nauman and 
others have bestowed upon it in the cases of leucocythaemia. The densi- 
ty of the enlarged glandular structures differs much in different cases. In 
some they are comparatively soft, while in others they are quite hard and 

18 



274 pernicious anemia. 

round. In the softer cases the increased growth is owing mostly to the 
accumulation of lymphoid cells with but little increase of the fibrous or 
connective tissue, while in the hard variety the reverse is the case. But 
in neither is there any deposits or new material differing from the natural 
elements belonging to the lymphatic or reticulated tissues; and both are 
distinguished from the scrofulous enlargements by the absence of all ten- 
dency to either caseous or purulent degeneration, and from cancerous 
growths by the absence of any tendency to permeate and absorb into the 
tumors any and all surrounding structures, or to end in open offensive ulcer- 
ated surfaces. The fact that in pseudo-leucocythaemia the spleen, lymphatic 
glands and other adenoid structures, are even more enlarged from the ac- 
cumulation, of white corpuscles and lymphoid cells, than in leucocythaemia, 
while the blood itself contains no notable increase of these bodies, would 
seem to show that their existence in the blood in such excess in cases of the 
last named disease, is not owing to their having been developed in these 
hypertrophied tissues and pushed out into the blood, as supposed by many 
writers; because careful examinations have shown that the vessels and 
ducts of the glandular structures are as free for them to make their exit in 
the one form of disease, as in the other. 

From a careful comparison of the clinical history and morbid anatomy 
of these two diseases, I am satisfied that they are only varieties or grada- 
tions of one and the same general morbid condition. There is the same 
failure in the production of haemoglobin and red corpuscles in both; while 
in the cases classed as leucocythaemia the white corpuscles continue to 
;be formed faster than they can be used in the excessive growth of the 
glandular structures, and consequently accumulate in the blood; and in 
those classed as pseudo-leucocythaemia the growth of the glandular and 
•adenoid structures absorb them as fast as they are formed. This does 
jiot indicate that the latter disease is any milder than the former. On the 
contrary, its average duration before reaching a fatal result, is somewhat 
less. As there is nothing more known concerning the causes, pathology, 
and treatment, of the pseudo, than of the true leucocythaemia, all that I 
lhave said in regard to the hygienic and remedial management of the lat- 
ter is equally applicable to the former. Under the impression that the 
disease had its primary seat in the lympho-sarcomatous tumors or hyper- 
trophied glands, some efforts have been made to reduce these by electrol- 
ysis, but without encouraging results. Under the same impression, some 
surgeons have extirpated the entire growths, without perceptibly in- 
terfering with the progress of the disease. The only cases in which sur- 
gical operations are justifiable, are those presenting some one or more 
tumors, so situated that their pressure directly interferes with some im- 
portant function, as when they crowd upon the larynx, trachea, or oesoph- 
agus. 

PERNICIOUS ANiEMIA. 

Cases are occasionally met with, presenting the same persistent anaemic 
condition, or loss of the haemoglobin, as in the two diseases just described, 
but without the increase of white corpuscles seen in leucocythaemia, and 
without the enlargements of the spleen and lymphatic glands accompany- 
ing pseudo-leucocythaemia. These have been grouped, by most recent 
writers, under the name of pernicious ancemia. They occur most fre- 
quently between the ages of twenty and thirty-five years, and somewhat 
more frequent in females than in males. It has been alleged, that fre- 
quently recurring pregnancies, protracted nursing, severe haemorrhages, 
insufficient food, and too much exposure to wet and cold, act as causes 



SYMPTOMS. 275 

favoring the development of this form of anaemia. At most, however, 
they can only be regarded as predisposing influences, while the efficient 
cause is unknown. Indeed, one of the chief characteristics of this group 
of cases, as alleged by most writers, is that the condition of the patient is 
not to be explained by the presence or action of any of the well known 
causes of simple anaemia. The disease was mentioned by Andral as early 
as 1823, but was first accurately and fully described by Addison, under 
the name of idiopathic ansemia. Lebart called it "essential anaemia;" 
Beismer, "progressive pernicious anaemia," while Flint, Pepper, and 
others, with more propriety, call it " pernicious anaemia." 

Many writers regard it only as an extreme or unusually severe form of 
ordinary anaemia, and it must be acknowledged that there is no very clear 
line of distinction, either in the symptoms or in the pathological changes 
between the simple and the pernicious. 

Practically, the diagnosis is based mainly on the fact that ordinary cases 
of anaemia are traceable directly to some prior pathological condition, such 
as excessive loss of blood, insufficient food, malaria, amenorrhoea, etc., 
while those called pernicious arise without any such manifest preceding 
conditions. 

Symptoms. — Consequently, if you see a patient with pallid counte- 
nance, soft, quick pulse, pale, clean tongue, variable appetite, with oc- 
casional nausea and temporary turns of diarrhoea, loud blowing sounds 
over the base of the heart and aorta, synchronous with the systole; short- 
ness of breath on attempting active exercise, great sense of weakness, 
with occasional feelings approaching syncope, and learn that these 
symptoms have developed gradually and persistently without any manifest 
cause, you will be justified in regarding the disease as pernicious 
anaemia, and may reasonably expect all the symptoms connected with res- 
piration, circulation and haematosis to increase, regardless of your treat- 
ment, until temporary exacerbations of fever, haemorrhages and dropsi- 
cal effusions determine a fatal result, or the patient dies suddenly from 
failure of the action of the heart. In the advanced stage of this variety 
of anaemia, haemorrhagic extravasations not unfrequently take place in 
the retina, causing suddenly, partial or complete blindness. In the 
same stage, the muscular force of the heart becomes so impaired and 
irregular, in many cases, that the slightest exertion brings vertigo, ring- 
ing in the ears, nausea and approaching syncope. 

Morbid Anatomy. — Post mortem examinations reveal apparently the 
same changes in the blood as in pseudo-leucocythaemia, only more ex- 
aggerated. The corpuscular elements, both white and red, are extremely 
reduced in number, w T hile those remaining of the latter, contain one-third 
less of haemoglobin than natural. In two or three instances reported, 
the spleen was moderately enlarged, but in none have the lymphatic 
glands been materially altered from the natural size. Fatty degenera- 
tion of the muscular structure of the heart has been found in a large 
proportion of cases, and sometimes dilatation with thinning of the walls 
of the ventricles. Several investigators have reported changes in the 
marrow of the bones similar to those found after death from leucocy- 
thaemia.* 

Changes of less importance have been found in many other structures, 
but only such as are common in all cases of extreme anaemia. 

Treatment. — The general indications for treatment, both hygienic and 
medical, are the same as I have detailed in regard to the management of 

* See, paper by Dr. Wm. Pepper, in Amer. Journal of Med. Sciences for April, 1877. 



276 addison's disease. 

leucocythaemia. The absence of spleenic and glandular enlargements, 
leaves less indication for the use of iodine and mercurials, either inter- 
nally or for local application. But in all other respects the treatment 
must be essentially the same. Transfusion of blood has been tried in 
several cases, both in this country and in Europe. Dr. 0. Carey reports a 
case in the Buffalo Medical and Surgical Journal for Januarv, 1881, 
which'recovered, after receiving, by transfusion, two fluid ounces of human 
blood. In nearly all the cases, however, in which this measure has been 
resorted to, no apparent benefit was obtained. In a communication to 
the Medical Press and Circular for October, 1879, Dr. Austin Welden 
claims to have cured/owr cases by the intravenous injection of milk. To 
complete a brief consideration of the group of persistently fatal anaemias, 
I must direct your attention to one more aspect which they assume, as 
first differentiated and accurately described by Dr. Thomas Addison, in 
1855, and by him called bronzed skin disease, but since, generally called 

ADDISON'S DISEASE, OR MELASMA SUPRA-RENALIS. 

This form of disease occurs most frequently in the early part of adult 
life, and much oftener in males than in females. Since the publication of 
Dr. Addison's views, the disease has been carefully investigated by Drs. 
Wilks, Greenhow, Letulle, and others, but without adding materially to 
our knowledge concerning its causes, pathology, or treatment. Its early 
stage is characterized by the same obscure symptoms as in pernicious 
anaemia. The patient experiences a gradual loss of strength, or ability to 
endure either mental or physical exercise; his appetite becomes variable, 
with occasional turns of nausea or diarrhoea; he gets shortness of breath, 
palpitation, and sometimes vertigo, from slight exertion, without any ap- 
pearance of emaciation; his countenance becomes pale, his pulse frequent 
and weak, with slight anaemic cardiac murmurs, yet the tongue remains 
moist and clean, and the secretions generally natural. In many cases, 
there are dull pains in the back and limbs, with temporary paroxysms of 
fever. The only symptom that will enable you to distinguish these cases 
from all the other forms of anaemia, is the development of dark, bronze- 
colored spots on the cutaneous surface. They generally appear early in 
the progress of the disease, and are most noticeable on the forehead, front 
part of the chest and abdomen, and on the backs of the hands. They are 
at first light brown, and vary much in size and shape, but they generally 
increase in size, and deepen in color, as the disease advances, until, in 
some cases, a large part of the whole cutaneous surface is a deep bronzed 
hue. In other cases the spots are small and few in number, but equally 
characteristic in color. Similar discolored spots also, in some cases, ap- 
pear in the mucous membrane of the mouth and fauces. 

In the majority of cases the disease advances steadily, causing the sense 
of exhaustion, the disturbances of circulation and breathing, and the turns 
of gastric and intestinal irritation, to be more frequent and severe until 
the patient dies from asthenia in from six months to two years; the average 
duration being about eighteen months. Yet occasionally a case occurs in 
which the progress of the symptoms is apparently suspended for several 
months at a time, thereby protracting the whole duration to five or six years. 
Two such cases have come under my own observation. Both were men 
between 35 and 40 years of age. One of them had been exposed to much 
hardship and confinement in close air, on board one of the iron monitors 
in active service during the recent war. 

Some symptoms of the disease appeared soon after the war closed, as 



PATHOLOGY. 277 

earlv as 1865. But they progressed so slowly, with several periods of ap- 
parent suspension, that the fatal result was not reached until 1875. I did 
not ser him until near the fatal result. The discolorations of the skin 
over the abdomen and lower part of the chest, were strongly marked; and 
but little less so over the forehead, temples, and backs of the hands. For 
ral months he had been unable to walk across his room without ex- 
treme feelings of exhaustion, and the final collapse resulted from protract- 
ed diarrhoea and vomiting. 

A post mortem examination showed the body not much emaciated; the 
blood in the heart pale and only partially coagulated; the liver and spleen 
of normal size and color; the mucous membrane of the stomach and ilium 
cjnirested, softened in some places, with abrasions; but no other morbid 
appearances were noticed except in the suprarenal capsules. Both of 
these were enlarged to more than twice their natural size. One of them I 
here show you from the pathological collection in the college museum. 
It has been laid open by an incision directly through the center, and you 
see it composed of two distinct parts. The exterior is composed of gray 
fibrous tissue, with spots and streaks of yellowish color, firm in texture, 
and distended into the form of a sac, enclosing a mass of caseous matter, 
more than twenty-five millimeters (one inch) in diameter, and about the 
consistence of new cheese, except a thin layer on its circumference next 
to the capsule which was nearer the consistence of thick cream. The 
central mass appears to be identical in all repects with the caseous mat- 
ter found in scrofulous glands, while the gray fibrous tissue of the capsule 
shows, under the microscope, fuciform, lymphoid, and large granular or 
giant cells, in considerable numbers. 

The other capsule was similar to this, both in size and texture. This 
was in all respects a typical case of the disease, and its post mortem 
appearances well illustrated the essential pathological changes resulting 
from it in the great majority of cases. In some, however, the mesen- 
teric glands, in the vicinity of the suprarenal capsules, have been found 
enlarged, with partial caseous degeneration; in a larger number either 
tubercular or caseous deposits have been found in the lungs; and in a 
verv few, the spleen has been moderately enlarged. One or two cases 
are on record, in which the marrow of the bones was changed as in 
leucocythaemia. 

The three most constant and essential anatomical changes are, the 
anaemic condition of the blood, the bronzed color of the skin, and the 
degeneration of the suprarenal capsules. Yet two or three well au- 
thenticated cases have been reported, in which all the constitutional or 
general symptoms, and the characteristic bronze color of the skin were 
fully developed, but in which the post mortem examination showed the 
suprarenal capsules, entirely free from any appreciable morbid change. 
Much difference of opinion has been expressed in regard to the nature 
of the disease under consideration. Some regard the suprarenal cap- 
sules as the primary seat of the disease, and the general symptoms as 
secondary. Others, among whom are Virchow, Green how, etc., claim that 
all the symptoms arise from irritation of the sympathetic nerves and 
ganglia in the vicinity of the capsules. I think that all the facts con- 
nected with the clinical history of the disease, are best explained by 
placing it in the same category with leucocythaemia, pseudo-leucocythae- 
mia, and pernicious anaemia; and regarding the failure in the processes 
of assimilation, by which the haemoglobin and corpuscular elements of 
the blood become deficient as the primary and essential pathological 
condition, while the changes in the skin, suprarenal capsules, etc., etc., 



278 CARCINOMA. 

are secondary. Much the same view has been expressed by Dr. Wm. 
Pepper, who regards the disease as primarily a profound impairment of 
the blood-forming function. Neither from my past clinical experience, 
nor from the known pathological changes which take place in the blood and 
tissues during the progress of the disease, can I give you any better sugges- 
tions for its treatment than those made in reference to the management 
of leucocythasmia and pernicious anaemia. They are all summed up in 
the use of such means, hygienic and medical, as are best calculated to 
restore the function of haematosis, and palliate the more distressing 
symptoms as they arise. 



LECTURE XXX. 

Carcinoma— Its Local Varieties, Anatomical Structures, Modes of Development, Diagnostic Feat- 
ures Prognosis and Treatment : Constitutional Syphilis— A brief allusion to the varieties of its 
manifestation, and the most reliable methods of treatment. 

GENTLEMEN: In the list of constitutional diseases I enumerated carci- 
noma, or cancer, and in doing so, I alluded to its acknowledged hered- 
itary character as the chief evidence that it was derived from a prior 
special diathesis. I am aware that a large proportion of both pathologists 
and practical surgeons, at the present time, regard all the varieties of 
cancer as primarily of local origin, and represent the general failure, or 
cachexia as secondary, and directly dependent on the diffusion of cancer cells 
from the point of their local origin. They freely admit its capability of 
hereditary transmission; and even allege this as its chief mode of propa- 
gation, leaving us to infer, from their expressions, that there is a specific 
germ transmitted which finds lodgment in the new being, as the nucleus 
of a future local morbid growth. It is not difficult to conceive the possi- 
bility of having the germinal cell of the ovum, or the spermatozoa^ of the 
semen, impressed with the same deviation from the natural condition of 
the properties inhering in each, atom of living matter belonging to the 
parent in which such germinal cells or spermatozcae was originally develop- 
ed; and that such deviation in the properties constituting the formative 
forces might ultimately so increase as to develop such changes both in the 
production and arrangement of cells and tissue elements, as to constitute 
morbid growths. But that a specific cancer germ should be thus trans- 
mitted, and retained through a period of forty or fifty years, and then be- 
come the nucleus of a local cancerous growth, is certainly very difficult 
to comprehend. To my mind, the generally admitted hereditary character 
of the disease, coupled with the persistent tendency to reproduction after 
the extirpation of the local tumors, constitute sufficient evidence that, 
however obscure it may be, there is a special constitutional condition that 
predisposes to the development of the local morbid growths. That such 
diathesis or constitutional tendency is not characterized by any apprecia- 
ble symptoms, I admit. But the same is true of the tuberculous, gouty, 
and rheumatic diatheses; yet no one appears to doubt the existence of 
such diatheses on that account. 

Causes. — Aside from hereditary influences, the causes of carcinoma are 



VARIETIES. 279 

but little understood. My own observations and study have led me to the 
conclusion that the free use of tobacco, alcoholic drinks, and meat, have 
some influence in favoring the development and progress of this form of 
disease. I think a careful analysis of vital statistics will show that the 
people of those countries in which these several agents have been most 
freely and universally used, furnish the highest ratio of deaths from the 
different varieties of carcinoma. Statistics also indicate that density of 
population exerts a predisposing influence. Still we have very little accu- 
rate knowledge concerning the causes of any variety of cancerous disease. 
Varieties. — The local developments of cancer, present such differences 
in their appearance, density and rapidity of growth, as to constitute several 
varieties. Those most generally recognized are the scirrhus, encephaloid 
and colloid. The first is charcterized by great density of structure and 
generally, slowness of growth. The second is softer to the touch, more 
rapid in growth, and generally attains much larger size. The third is in- 
termediate both in density of structure and rapidity of development. 
These several varieties are not made up of essentially different structural 
elements nor do they depend altogether on the character of the structure 
in which they are developed. It is true that the scirrhus, or hard variety 
is found most frequently in the skin, the female breast, the uterus, the 
stomach, and the lymphatic glands ; the encephaloid in the liver, kidneys, 
structures of the eye and brain ; and the colloid in the peritoneum, mesen- 
tery, and intestines. When any of the varieties of cancer originate in the 
epithelium of the skin or mucous membranes, it is generally called an 
epithelioma. When in the structure of bone it is called an osteo-sarcoma. 

Anatomical Structure. — Soon after the microscope was applied to the 
study of minute organic structures, both healthy and morbid, it was 
thought by many observers that cancerous growths contained character- 
istic cells, peculiar to themselves and sufficiently distinctive to consti- 
tute a reliable diagnostic feature. Minute descriptions were given of these 
supposed peculiar cells, and of their mode of multiplication and diffusion. 
And you still find in all your books expressions used in relation to cancer 
cells, which fairly imply some peculiarity in their character. But it is now 
universally admitted that there are no cells or other organic elements 
peculiar to cancerous growths. On the contrary, they all consist of es- 
sentially two structural elements, namely, cells, and fibrous, or connective 
tissue. The cells vary in size and shape, but, as a rule, closely resemble 
the natural epithelial cells of the tissue in which the cancerous growth 
originates. They are usually larger than the leucocytes of the blood, 
and contain either nuclei or granules. The fibrous tissue, which consti- 
tutes the matrix, in the meshes of which the cells are collected, presents 
no characteristics which will enable you to distinguish it from the con- 
nective tissue of healthy structure. 

The principal features of a cancerous structure, which distinguish it 
from other structures, are not any peculiarity in the form or appearance 
of either the cells, or the fibrous structure, but in the relations which these 
two tissue elements bear to each other. The fibrous structure is so ar- 
ranged as to leave interspaces or alveoli of varying size and shape, and the 
cells, instead of being somewhat equally distributed along the fibres, are, 
for the most part, collected into clusters in these alveoli. This arrange- 
ment is characteristic of all the varieties of cancer, and gives to the cut 
surface, when magnified, the appearance of clusters of cells, varying in size 
and number, with intervening bands of fibrous structure. In the scir- 
rhus, or hard cancer, the fibrous tissue predominates, and the alveoli con- 
taining cells are small; which has caused this variety to be called by some 



280 CARCINOMA. 

observers, fibrocarcinoma. In the encephaloid or soft cancer, the fibrous 
tissue is less abundant, and the alveoli or interspaces are much larger, and the 
cells correspondingly more abundant. Hence it has been called, medul- 
lary-carcinoma. The colloid variety also contains less fibrous tissue than 
the scirrhus, but the alveoli contain a less number of cells than the en- 
cephaloid, the deficiency being supplied by an unorganized gelatinous ma- 
terial, which has caused this variety to be called, gelatiniform carcinoma. 
There is also in all the forms, a modification of this gelatinous material, 
which may be pressed out of the cut surface of fresh cancer structure, and is 
often called cancer-juice. In the scirrhus variety the quantity of this fluid is 
very small. All cancerous structures contain some vessels and nerves, and 
when the integument gives way over the prominent part of the softer va- 
rieties, a ver} 7 - rapid and highly vascular fungus growth is developed, which 
bleeds on the slightest touch. In former times such cases were called 
" fungus-hagmatodes." In the progress of development or growth, the 
cancerous structure exhibits a constant tendency to invade and convert 
into itself, all other structures with which it may be in contact. It does 
not merely push them aside to make room for itself, like other tumors, 
but rather absorbs them into itself. In addition, the cells appear to 
follow the lymphatic vessels into the neighboring lymphatic glands, causing 
in them secondary cancerous growths. A similar extension may also take 
place along the blood vessels, causing many little masses or nodules to 
form in the vicinity of the original growth, more especially when the 
cutaneous surface is involved. 

Diagnosis. — From what I have already said, you will readily infer that 
the chief diagnostic features common to all cancerous tumors, are the as;- 
gregation of the cells in clusters, filling the alveoli or spaces formed by the 
interlacing of the fibrillated structures; the indiscriminate conversion of 
adjacent structures into a part of itself ; The induction of secondary 
growths in the neighboring glandular structures, and its persistent tend- 
ency to deteriorate the general health, and ultimately to destroy the life of 
the patient. While these features are sufficient to enable you to diagnos- 
ticate the various external or superficial cancerous growths, they are not 
available, except to a limited extent, when the diseased mass is developed 
in the parenchyma of internal organs. In the latter cases there must be 
added a careful comparison of their clinical history in each tissue or organ, 
with that of other local affections in the same parts. This can better be 
done in connection with the consideration of local diseases than at pres- 
ent. Yet there are certain clinical phenomena, pretty uniformly present 
in the several stages of all internal cancerous affections, which are suffi- 
ciently distinctive to merit your attention: 

1st. When once begun, there is a degree of uniformity and persistence 
in the symptoms accompanying the local development of a cancerous 
disease, that does not characterize either functional disturbances or 
chronic inflammations in the same parts. 

2nd. The pain in cancer is rarely continuous unless from direct pressure 
of the tumor on surrounding sensitive parts, but is lancinating, of short 
duration, and recurs at irregular intervals. There is also less tenderness 
to pressure or percussion than in chronic inflammation. 

3d. There is a progressive impoverishment of the red corpuscles of 
the blood, causing a steadily increasing pale or sallow color of the surface, 
with little emaciation, and generally no increase of temperature or 
frequency of pulse. When the disease is located in the stomach, however, 
the emaciation becomes more marked, especially in the advanced stage, on 
account of the inability to take and assimilate food. 

4th. At some stage in the advancement of the disease, it causes sufficient 



PROGNOSIS. 281 

enlargement of the structure or organ in which it is located, to be capable 

of detection by palpation and percussion, when its location, size, density, 
and other physical qualities, will aid in rendering the diagnosis certain. 

Prognosis. — The tendency of all true cancerous affections is to steadily 
increase, both in local development and in general impairment of the 
health, until the life of the patient is destroyed. The rate of progress 
varies much in the different varieties of carcinoma, and is also influ- 
enced, in some degree, by the character of the structure involved. As a 
rule the scirrhus variety progresses much slower than the encephaloid; and 
the more vascular the tissue in which the local growth originates, the more 
rapid is its progress. Some rare cases have been observed in which the 
cancerous structure appeared to undergo partial fatty degeneration with 
some diminution of size, and then remain stationary for several years. 
But it may be said properly, that there is no tendency to a spontaneous 
cure by complete resolution or disappearance of the cancerous structure. 
Neither does there appear to be any hygienic or medical treatment known 
that is capable of affecting a cure with any degree of certainty. I have 
seen a considerable number of cases of scirrhus of the breast, and of some 
other parts, relieved entirely of pain and their growth much retarded, by 
confining the patients to a milk and vegetable diet, and excluding meat, 
with the protracted use of certain medicines. The fact that cancerous 
growths have neither a tendency to spontaneous cure, nor to disappear 
under medical treatment, has caused them to be very generally placed in 
the hands of the surgeon for extirpation; and not a few go to pretended 
" cancer doctors," to be murdered by caustics under the name of cancer 
salves and plasters, or to be occupied a few months in drinking clover tea, 
or some other equally harmless infusion. 

If the cancerous tumor is so located that it can be safely removed, the 
surgeon generally proceeds at once to extirpate it as completely as possi- 
ble, without any special preparatory or subsequent constitutional treatment. 
The result is, that, except in the mildest form of cutaneous epithelial 
cancers, such as occur most frequently on the lip, the disease returns in 
from four months to three years, and causes a more rapid failure of the 
patient than before the operation. Consequently, so far as permanent re- 
sults have been obtained, they are no better from surgical than from med- 
ical treatment. 

This leads us directly to the question whether there is any treatment that 
is capable of either mitigating or curing cases of the true cancerous forms 
of disease? My own clinical observations would not justify me in giving 
an unqualifiedly negative answer to this question. 

Treatment. — And yet there is great difficulty in arriving at just and reli- 
able conclusions concerning it. This arises from the fact that nearly all 
the methods of treatment adopted, have been founded on the idea that 
cancers originate locally from some specific germ or cell, the multiplication 
of which not only causes the morbid growths, but also the general failure 
of health by their diffusion in the blood. The logical inference from this 
pathological view, is, that the earlier the local tumors can be removed the 
less danger will there be of either constitutional impairment or renewal of 
the local growth. 

Hence, the chief anxiety of the surgeon has been to operate early and 
to remove all the visible cancerous tissue, as the only hope of cure. And 
in cases where surgical procedures were not admissible, the leading thought 
has been to find some specific that would be capable of such administra- 
tion as to destroy the supposed cancer cells or germs in the system. So 
prominent w T as this idea of finding some specific remedy capable of curing 



282 CARCINOMA. 

or destroying the cancer germs, that more than a quarter of a century 
since, the late Dr. Daniel Brainard, of this city, after numerous experi- 
ments thought he had found such a specific in the lactate of iron, a solu- 
tion of which he found very active in dissolving pieces of cancerous 
tumors. He also ascertained by careful experiments on dogs, that a weak 
solution of the lactate of iron could be safely injected into the veins of 
the living animal. 

With these preliminary facts ascertained, he became very confident that 
cancers could be permanently cured by removing with the knife all the 
visible cancerous tumors, and then destroying the cells or germs remain- 
ing in the blood by the intra-venous injection of a solution of lactate of 
iron. He made a fair trial of this method in, at least, two cases that came 
under my own observation. One was an adult male, with a well devel- 
oped encephaloid tumor, originating in the eye-ball, and occupying the 
whole cavity of the orbit. He removed the diseased mass very perfectly 
by the usual operation, and injected a solution of the lactate of iron into 
the venous blood through the vein in the arm, which is usually opened in 
performing venesection. The injection was repeated two or three times, 
at intervals of from four to six days. The wound in the orbit granulated 
and healed up, with a healthy appearance, and the case was reported, and 
published in the American Journal of Medical Sciences, as permanently 
cured by extirpation and intra-venous injection of lactate of iron. Un- 
fortunately, however, before the ink was fairly dry on the pages of the 
journal, the cavity of the orbit was being again rapidly filled with a re- 
newal of the cancerous growth, and in about eighteen months the patient 
died from the effects of the disease. 

The other case was a well developed scirrhus in the breast of a female 
aged about fifty years. The whole breast was removed by an operation, 
and the solution of lactate of iron injected through the vein in the arm, 
as in the previous case. Before the end of the first week after the opera- 
tion, symptoms of septicemia supervened, and the patient died. 

I think the same treatment was tried in two or three other cases, with- 
out encouraging results, and was abandoned.* 

The very recent confident assertions of a Dr. De Olat concerning the 
curability of cancerous and other malignant diseases, by the use of pure 
phenic or carbolic acid, are founded on the same idea of specific cancer 
cells or germs and specific remedies for their destruction. And it is safe 
to say, that whoever resorts to his particular remedies and methods of 
using them, will soon demonstrate thoir entire inefficiency. Indeed, it is 
only a few days since, that I was called to see a lady who had suffered 
severely from a well marked scirrhus tumor in the pyloric portion of the 
stomach. I learned that for about three months past, she had faithfully 
used the exact remedies and methods of treatment recommended by Dr. 
De Clat. She had used one preparation by the mouth, another by hypo- 
dermic injection, and a third by inhalation. Yet they had exerted no ap- 
parent effect on the progress of the disease ; certainly no mitigating in- 
fluence, for she had steadily failed or grown worse in all respects. It is 
now generally conceded by the most experienced microscopists and 
minute anatomists, that no peculiar germs, nor specific cells, have been 

* A fact worthy of notice, fcr the guidance of other experimenters, wa ascertained during the 
trials of lactate of iron in solution for intra-venous. injection. So long as the pera ing surgeon 
succeeded in introduc ing the solution wholly into the current of venous b ood, it appeared to 
produce no noticeab e disturbing effect. But twice the operator, by mistake, injected some into the 
areolar tissue outside of the vessel, and once without mis:ake, but for a purpose, he injected it into 
the popliteal artery. In the two first it speedily destroyed every vestige of the areolar tissue with 
whi.'h it came in contact ; and in the last, being carried with the arterial vp>od directly into the 
capi laries of the leg and foot, ,t rapidly induced in them an inflammation so intense as to jeopard- 
ize the patient's life. 



TREATMENT. 283 

discovered in any of the varieties of cancerous structure. On the contrary, 
the cells and fibrous tissue composing the various cancerous growths, are 
either identical with, or only modifications of the natural epithelial cells 
and connective tissue of the part in which the cancer is located. The 
peculiar aggregation of the cells, and their modification, const tuting the 
cancer structure, is doubtless the result of a morbid condition of the prop- 
erties which control the primary forms of organization, either derived from 
hereditary influence or the slow and persistent action of such causes as 
are capable of modifying the processes of assimilation and cell evolu- 
tion. This view would lead us to expect better results from the persistent 
adherence to proper hygienic regulations, and the use of such remedies as 
are capab'e of modifying the elementary properties of the tissues, than 
from either specific medication or simple surgical extirpation, or both com- 
bined. The direct removal of an existing morbid growth or tumor by 
either knife or caustic, does not in any degree change either the quality 
of the blood or the properties that govern the development of tissue ele- 
ments and their aggregation into definite structures. And if these remain 
unaltered, there is every reason to suppose that they will sooner or later 
lead to the same result, namely, the renewal of the morbid growth in the 
same or some other place. A supposition which is in direct consonance 
with all past experience. 

The rational indications then, are, to put the patient upon such diet and 
mode of living, aided by such general alterants, as will be best calculated 
to change the properties governing the development of tissue elements, 
and especially the epithelial cell formations. If, by such management, 
the cancerous growth ceases to be painful and remains stationary in size 
for two or three months, and is so situated that it can be safely removed, 
it should then be extirpated as completely as possible, and the hygienic 
and general medical treatment continued faithfully for one or two years. 
By thus first altering the quality of the blood and the properties controll- 
ing tissue growth, then extirpating the morbid structure already developed, 
and continuing for a long' time subsequently the same modifying influences 
as at first, you will give the patient the best possible chance for a perma- 
nent cure. But you are doubtless ready to ask whether I have any evi- 
dence that the progress of true cancerous diseases can be materially 
influenced either by hygienic or medical treatment? I am confident that 
such evidence is in my possession, especially in relation to the scirrhus or 
hard variety of cancers. The encephaloid cases appear to be much less 
under the control of any measures yet devised. At an early period I saw 
the opinion expressed by some one worthy of credit (perhaps by the elder 
Dr. Jackson, of Boston, in one of his letters to a young physician), that 
adherence to a diet of milk, farinaceous articles, vegetables and fruits, ex- 
cluding meat, would much retard the progress of malignant tumors. Act- 
ing in part upon this suggestion, in 1848, while residing in New York City, 
I took charge of a poor woman who had presented herself in the surgicai 
clinic of Dr. Willard Parker, and had been dismissed with the opinion that 
surgical interference was inadmissible, as both breasts were nearly de- 
stroyed by open scirrhus cancers, and what soft parts were left, were closely 
adherent to the ribs. I advised her to adhere rigidly to the diet just men- 
tioned, use tea and coffee only lightly, and nothing of fermented or dis- 
tilled drinks. 

I gave her the bichloride of mercury in doses of two milligrams (gr. 
1-32) three times a day, generally in connection with some simple bitter 
infusion; and instructed her to keep herself supplied with fresh stramo- 
nium ointment with which to dress the open cancerous ulcers morning and 



284 CARCINOMA. 

evening. She made the unguent by simmering fresh stramonium leaves 
gathered from the roadside, with lard. The patient carried out my instruc- 
tions faithfully and patiently for little more than twelve months, during 
which time the local cancerous disease had ceased to be painful, and in- 
stead of extending, actually showed some limited places of cicatrization, 
and her general health was improved. I then removed from the city and 
know not what became of the case afterward. Since that time I have had 
an opportunity to note the effects of a simple milk and vegetable diet, 
without meat, accompanied by good air, and the use of small doses of either 
the bichloride of mercury or the arseniate of sodium with conium, inter- 
nally, in a large number of cases of carcinomatous disease. And in no case of 
the hard variety of cancer, except when located in some part of the stom- 
ach, have I known the treatment fail to relieve the pain and arrest the 
growth in less than two months; and the gain thus made was usually re- 
tained as long as the treatment was continued. 

But in no case was I able to obtain more than a slight reduction in the 
size of the local cancerous tumor. And such is the anxiety felt by most 
patients so long as they know the tumor remains, and so frequent the in- 
terference of friends in advising this specific or that doctor, as certain to 
cure, that only a very small proportion of the whole number of pitients 
have adhered faithfully to the prescribed diet and medicines more than 
three or four months without interruption. And even in those cases, 
in which, after one or two months of preparatory treatment, the tumor has 
been removed, so soon as the wound has fairly healed, and there is a fair 
appearance of recovery, the great majority will at once return to a promis- 
cuous diet and abandon further treatment as unnecessary. Among my 
patients I have found a few exceptions to the general rule. At. least 
twenty years since an intelligent married woman, aged thirty-eight years, 
from a neighboring state, came to me with a well marked scirrhus cancer in 
the right breast. The tumor was about fifty millimeters (two inches) in 
diameter, occupying the central part of the mammary gland, causing re- 
traction of the nipple, and some adherence of the integument to the hard 
mass. It was but little sensitive to the touch, but was subject to occasion- 
al lancinating pains, and had been gradually increasing in size since it 
was discovered, about eighteen months previous. The patient was thin 
in flesh, but otherwise in apparent good i.ealth. The cancerous affection 
was hereditary in her family, both her mother and grandmother having 
died from cancerous disease. She had N come expecting to have the tumor 
immediately removed. But when I explained to her that a removal of her 
breast would neither change the quality of her blood, the properties of her 
tissues, nor the hereditary family tendency, and that unless these could be 
first changed, the local development of cancerous tissue would be very 
certain to follow within a few months, she readily consented to postpone 
the operation for a preparatory treatment of two months. She adhered 
strictly to a milk and vegetable diet, spent much time in the open air, and 
took one of the following piils after each meal-time. 

]J Sodii Arseniatis 0.250 grams gr. iv 

Extracti Conii 4.000 " 3i 

Mix, divide into sixty pills. 

At the end of the two months she returned, in apparent good health, hav- 
ing had no twinges of pain in the tumor during the last three or four 
weeks, and so far as could be judged by careful measurement, no increase 
in the size of the tumor. I now removed the entire breast, by the usual 



TREATMENT. 285 

operation, leaving enough of the integument to enable me to close up the 
wound by sutures. The part was covered with simple dressing's without 
antiseptics in any form. The same diet and medicines were continued as 
before the operation. The wound healed rapidly, cicatrization being com- 
plete in three weeks, when she returned to her home, where she could en- 
joy good air and all the comforts of life. She continued under my direc- 
tion, however, through correspondence with her husband, for two years. 
During all the first year she continued to take the pills of arseniate of 
sodium and extract of conium; omitting them only three times, for four 
or five days at a time. During the second year she omitted the pills every 
third month, and subsequently omitted them entirely. At no time, how- 
ever, did she return to the use of meat as an article of diet. At the end 
of three years and six months, she visited me in good health; and at two 
subsequent times when visiting this city she called at my office; the last 
time about thirteen years after the extirpation of the breast. She was 
still in good health, and a careful examination could detect no appearance 
of cancerous development in any part of the system. She was enjoying 
her milk and vegetable diet as usual, with no apparent disposition to 
abandon it. Since that time I have neither seen nor heard from her. I 
am satisfied that the same management, executed with the same faithful- 
ness and perseverance, would result in the permanent cure of a very large 
proportion of all the cases of scirrhus or hard cancers, so located that they 
could be extirpated at the proper time. And even in the cases where the 
cancerous growth cannot be extirpated, its progress may be greatly re- 
tarded and the life of the patient much prolonged. In proof of this, I 
could cite several cases of well marked cancer of the uterus and its append- 
ages. In cancer located in any part of the stomach or oesophagus, I have 
found a milk diet, and the use of the following formula to afford more re- 
lief than I could obtain in any other way. 

^ Acidi Carbolici 0.50 grams gr. viii 

Glycerine 15.00 c. c. 3iv 

Tincturae Gelsemini 15.00 " 3iv 

Tincturas Opii Camphoratae 60.00 " |ii 

Aquse 60.00 " §ii 

Mix. Give four cubic centimeters (fl. 3i), just before each regular meal 
time, and at bed time. In the early stage of the disease, I have some- 
times added two minims of the liquor potassii arsenici (Fowler's solution) 
to each dose, with apparent benefit. Dr. Bartholow decidedly recom- 
mends, in the same class of cases, small doses of an equal mixture of pure 
carbolic acid and iodine.* In the more rapidly developed encephaloid 
growths in the liver, kidneys, structures of the eye, etc., I have seen- but 
little influence exerted by diet or medicine, and in no instance have I 
known a case of that variety to be permanently relieved by surgical oper- 
ations. In the present state of our knowledge, the services of either phy- 
sician or surgeon are limited, in such cases, to the judicious use of such 
diet, and anodyne medicines as will best palliate the suffering of the patient, 
and thereby render the brief period he has to live as comfortable as possi- 
ble. 

For further details in regard to the local development of cancerous 
diseases, and the surgical procedures for their relief, including the very 
recent operations for extirpation of cancers of the stomach and intestines, 
[ must refer you to the more recent valuable works on surgery. 

*See Practice of Medicine, by Roberts Bartholow, M. D., etc., etc., p. 48. 



286 CONSTITUTIONAL SYPHILIS. 



CONSTITUTIONAL SYPHILIS. 

Syphilis in all its forms and stages, is so fully presented to the profes- 
sion, both in special treatises and in general works on surgery, in addition 
to being in special courses of instruction in the medical schools, that I 
might be justified in omitting all allusion to the subject in the present 
course. Yet there are two or three conclusions to which 1 have been 
forced by my own clinical observations, that I deem of sufficient impor- 
tance to occupy your attention during the remainder of the present hour. 
Syphilis in all its forms is the result of the action of a specific virus gen- 
erally introduced into the human system by inoculation. Such inocula- 
tion usually takes place during impure sexual connection, but may be the 
result of accident, as when introduced into wounds on the fingers while 
dressing syphilitic sores, washing clothing impregnated with the virus; or 
in any other way bringing the matter in contact with an abraded or 
sensitive surface. 

The first effect of inoculation is the formation of a sore at the point of 
contact, from which, if not speedily destroyed, the poison is carried by the 
lymphatics to the nearest lymphatic glands, causing them to become in- 
flamed and swollen. The sore at the place of inoculation and the inflamma- 
tion of the adjacent glands constitute what is called primary syphilis. 
Whatever subsequent manifestations of disease occur, are the result of 
the introduction of the poison into the blood, and are called constitutional. 
Most writers divide the latter into secondary and tertiary forms of disease; 
but the distinction is for the most part arbitrary and without practical utility. 
The primary sores differ somewhat in different cases. In some, the sore 
is small with smooth edges and a hard base, and is called the hard or true 
Hunterian chancre. In others, it is larger in circumference, without hard- 
ness at its base, and with rather irregular excavated edges, and is called 
the soft chancre or chancroid. 

In still other cases more rarely met with, the sore is large, irregular, 
rapidly spreading, and accompanied by much tumefaction of the surround- 
ing areolar tissue, and is called the phagedenic chancre. The first of these 
sores does not generally appear until from five to fifteen days after the inocu- 
lation, spreads but little, and generally soon heals up. But the poison from 
it is very liable to reach the neighboring lymphatic glands, causing them 
to become swollen, tender, and hard, and remain so for two or three 
weeks, and then undergo resolution without suppurating. But their dis- 
appearance is almost always followed, in due time, by some form of con- 
stitutional disease. 

The second variety appears within from one to five days after inoc- 
ulation or contact with the poison, soon extends its poison to the lymphat- 
ic glands, causing more active inflammation, swelling and pain, and very 
generally ends in suppuration, forming abscesses, which are often slow to 
heal, but which are notso constantly followed by constitutional or second- 
ary manifestations. Indeed, many of the modern specialists in this de- 
partment, claim that the soft chancre originates from a specifically differ- 
ent poison from that which produces the hard variety, and is never followed 
by constitutional infection. The phagedenic chancre is only a severe 
form of the soft variety, accompanied by more diffuse inflammation, sup- 
puration, and sometimes even extensive sloughing. 

Now, gentlemen, while I freely admit the accuracy of the descriptions of 
all these varieties of primary syphilitic sores, and their relative tendencies 
to infect the neighboring glands, and at a later period to induce a succes- 



MANIFESTATIONS. 287 

sion of constitutional symptoms, one of the important conclusions I wish 
to give you is, that it is entirely unsafe to rely upon the doctrine that any 
one of these syphilitic sores, whether it be chancre or chancroid, will not 
be fo lowed by constitutional symptoms at some subsequent period of 
t'.ni'. 

In other words, if a patient comes to you with the most perfect speci- 
men of a soft chancre, and it is speedily followed by abundantly suppur- 
ating buboes or lymphatic glands, you cannot safely promise him that 
there will positively be no subsequent constitutional or secondary symp- 
toms resulting from the infection. Fori have repeatedly seen almost ev- 
ery variety of secondary and tertiary manifestation, in patients whose pri- 
mary sores were entirely Iree from induration, and whose groins were well 
scared from the original suppurated glands. 

Another conclusion based on direct clinical observation, is that you can 
never relv upon destroying a primary syphilitic sore so early and com- 
pletely as to certainly prevent the poison from entering the blood and in- 
ducing constitutional effects. 

That true chancres are sometimes thus completely destroyed and never 
followed by any secondary effects I freely admit. But in other cases 
when the primary point of inoculation has been attacked equally early, and 
to all appearance with equal effect, the subsequent history has shown 
abundant evidences of constitutional infection. There is, therefore, no 
reliable index by which we may know whether any given patient is safe 
from future trouble, until the lapse of time demonstrates it. 

The principal secondary or constitutional manifestations of syphilitic 
disease are cutaneous eruptions; specific inflammations and u'cerations of 
the mucous membrane of the fauces, nostrils and mouth; inflammation of 
the periosteum, especially that covering the bones of the nose and palate, 
the long bones of the extremities, and those of the cranium; and struct- 
ural degeneration, usually called syphiloma, in the parenchyma of internal 
organs, more especially the liver, kidneys, lungs and brain with its append- 
ages. For full descriptions of all these I must refer you to the lectures 
on surgery and dermatology, or to special' works on syphilitic diseases. 
I will only state that they are all the effects of a specific virus, primarily 
introduced into the system from without, and may vary much, both in the 
order of their manifestation, and in the length of time from the primary 
introduction. 

Long intervals may occur, even amounting to ten or twenty years, dur- 
ing w 7 hich patients once having had syphilis, may appear perfectly well, 
and yet become sorely afflicted with periosteal nodes or syphiloma of the 
nervous centers, etc. Consequently you can never assume to know cer- 
tainly, whether in any given case, the patient is perfectly and permanent- 
ly cured or not. 

Clinical facts also show that a wife may contract constitutional syphilis 
from the bearing of children congenitally affected with the disease from 
the father. This, with the preceding statement, will remind you that 
physicians are liable to meet with secondary or remote manifestations of 
the disease at times, and in families where they least expect them. It is 
not rare that a young married woman, belonging to a domestic circle that 
no one would suspect, after one or more abortions or premature deliveries, be- 
gins herself to fail in health, and soon presents unmistakable symptoms of 
some form of constitutional syphilis. Or the child may be born at full term, 
and in a few days its skin is found speckled with copper colored spots, or its 
mouth and nostrils occupied with the characteristic erythema. On the 
other hanl I have seen both m3n ani woman, in the advanced period of 



288 CONSTITUTIONAL SYPHILIS. 

life, after having reared families of apparently healthy children, and lived 
as exemplary and leading members of society for twenty-five or thirty 
years, become seriously afflicted with cephalalgia, derangements of vision, 
unsteadiness of gait, in one instance hemiplegia, and in another epilepsy, in 
which a careful examination showed well marked pericranial nodes and 
corresponding thickening of the dura-mater, with pressure upon the cere- 
bral surface; and all of which were relieved by well directed anti-syphilitic 
treatment. In one lady, at least fifty years of age, and mother of a family 
of grown-up children, the functions of the brain became so seriously dis- 
turbed that her attending physician, who from the circumstances of the 
family, had not so much as thought of a possible syphilitic influence, was 
very confident that she had effusion into the lateral ventricles of the brain. 
Seeing the patient in consultation, and passing my hand over the forehead 
and top of the head to note the temperature, I discovered two well devel- 
oped nodes over the upper part of the f. ontal and one over the parietal 
bones. 

After retiring to a private room for consultation, I asked the family 
phvsican if he knew anything in regard to syphilitic diseases in the early life 
of either the patient or her husband, and whether it was not possible that 
the present condition of his patient resulted from slow alterations of the 
structures inside of the cranium corresponding with the thickenings of the 
pericranial membrane visible externally. But finding him quite inclined to 
resent even the suggestion, and not wishing to have the family disturbed by 
any questions which might raise unpleasant suspicions I dropped the sub- 
ject, and without further questioning of his diagnosis, easily pursuaded 
him to put his patient upon the use of a prescription containing iodide of 
sodium, bichloride of mercury and conium; claiming that its alterative 
action would be more likely to induce absorption of the supposed serous 
effusion than any other remedies I could suggest. The result was, that 
in a few days the patient began perceptibly to improve, which encour- 
aged a continuance of the medicine ; and under its influence, in three 
months, all her cerebral symptoms as well as the nodes on the cranium had 
disappeared, and the patient was able to ride out and resume some charge 
of her household. It will be well for you to be ever on the alert for these 
remote and troublesome syphilitic affections, but when you meet them 
in families, affecting innocent parties, sometimes from hereditary influence, 
other times, as I have already intimated, from a husband either directly, 
or indirectly through placental connection with a diseased foetus, it is not 
necessary to create domestic discord and destroy the happiness of a whole 
life, by such inquiries as will at once suggest the real nature of the case. 
On the contrary, simply explain to the wife or mother that there is some 
chronic derangement of the nutritive processes, which will need careful 
treatment for some time, and proceed at once with the most reliable rem- 
edies for what you suppose to be the real disease. 

If the nature of the case is such as to indicate that the constitutional 
condition of the husband is still impure, inform him privately of his con- 
dition, and insist that he shall faithfully use the necessary means for cor- 
recting his own morbid condition. By such a course, the judicious and 
skillful physician can obviate an immense amount of moral, social, and 
physical evil, during his professional career. My views of the treatment 
of syphilis may be briefly stated in the following propositions: 

First. If I meet a primary sore, during the first three days after it becomer 
visible I immediately cauterize it freely either with strong nitric acid or 
liquid carbolic acid, with the hope of destroying all the virus before it has 
left the sore, or entered either the lymphatics or the blood. Subsequently 



TREATMENT. 289 

I have it dressed morning and evening with carbolated cosmoline or iodo- 
form until it is healed. If the sore or chancre is more than three days old, 
the cauterization may as well be omitted, and the iodoform or carbolated 
dressing applied from the beginning; for there is little or no probability 
that absorption of the virus can be prevented, and there is generally no 
difficulty in healing the sore. 

Second. As there is no absolute certainty that absorption of the virus 
will be prevented in any given case, I am in the habit of commencing at 
once, in all cases, the internal administration of mercury, or the prepara- 
tions of iodine, or both, as the most reliable means for neutralizing or ex- 
pelling so much of the poison as may have been taken up. If the patient 
is young and vigorous, I give one of the following pills three or four times 
a day: 

I£ Hydrargyri Chloridi Mitis ] .5 grams gr. xxiv 

Extracti Conii 1.5 " gr. xxiv 

Mix, divide into xx pills. 

If the patient is already anaemic or debilitated, I prefer giving four 
cubic centimeters (fl 3i) of the following formula, before each meal and 
at bed time: 

3 Hydrargyri Chloridi Coros. 0.1 gram gr. iss 
Extracti Conii Fluidi 15.0 c. c 3iv 

Tincturse Cinchonas Comp. 160.0 c. c. §v 



Mix. Put each dose with sweetened water when given. If the bowels dc 
not move regularly each day I prompt them by the mildest class of laxa- 
tives, and confine the patient to a mild plain diet, without any alcoholic 
drinks either fermented or distilled. If the gums and teeth do not become 
tender to pressure, and no swellings appear in the groins or neighboring 
lymphatic glands, I allow one or the other of these prescriptions to be 
continued until the primary sore is entirely healed, and then discontinue 
them on the presumption that none of the specific poison had been ab- 
sorbed, and further treatment is unnecessary. 

Third. If, however, in spite of the foregoing treatment, or from the 
delay of the patient before presenting himself, the lymphatic glands have 
become inflamed and swollen, whether they present any appearance of 
suppurating or not, I commence directly the administration of the iodide 
of sodium, bichloride of mercury, and conium, in accordance with the fol- 
lowing formula: 

3 Hydrargvri Chloridi Coros. 0.10 grams gr. iss 

Sodii Iodidi 15.00 " 3iv 

Extracti ConiiFluidi 15.00 c. c. 3iv 

Elixer Simplicis 145.000 " " |ivss. 

Mix. Give four cubic centimeters (il. 3i) in a little additional water 
before each meal time and at bed time. 

If the swollen glands are very tender and present indications of commenc- 
ing suppuration, I apply emolient poultices until the abscesses are sufficiently 
matured, and then open them freely, deeming it important to give the 
pus an early and free outlet. They are then washed out and dressed with 
antiseptic applications morning and evening until they become healed. 
If the affected glands are not large or tender and give no indication of 
19 



290 CONSTITUTIONAL SYPHILIS. 

suppurating, I dress them with mercurial ointment or a liniment of two 
parts of camphorated soap liniment and one of tincture of iodine, until 
they disappear. If the affection of the glands disappears either by reso- 
lution, or by suppuration and subsequent cicatrization, I continue the 
administration of the iodide and mercurial each morning and evenino- for 
three or four weeks, when, if no secondary symptoms appear, all medicines 
are discontinued. But the patient is warned to immediately apply for fur- 
ther treatment, should constitutional symptoms of any kind make their ap- 
pearance. 

Fourth. For all the forms of constitutional syphilitic disease, whether in 
the skin, the membranes of the mouth, fauces and nostrils; the periosteum, 
bones, or parenchyma of internal organs; I have found the combination of 
iodide of sodium, bichloride of mercury and conium, to come nearer to a 
reliable specific, than any or all other remedies that have been suggested. 
For many cases, the formula I gave you a few minutes since, is the best; 
but if the patient is already more or less debilitated, it is better to substi- 
tute the compound tincture of cinchona in the place of the simple elixer. 
I generally commence giving four cubic centimeters ( fl 3i) in a table- 
spoonful of sweetened water four times per day, for adults, and proportion- 
ately less for children. I allow a diet, embracing a fair variety of good 
plain food, but prefer the entire avoidance of alcoholic drinks and tobacco. 
In old anremic cases, and in generally depraved conditions of the system, I 
give in addition to the alteratives and good food, such additional tonics 
and nutrients as extract of malt and cod-liver oil; citrate of iron and qui- 
nine; or iron, quinine and strychnia; giving them usually after meals. I 
do not remember ever meeting a case, in which the iodide of sodium and 
^bichloride of mercury, given as I have suggested, did not relieve the pains 
of syphilitic nodes in four or five days, with a subsequent reduction of the 
swelling. Neither have I ever met with syphilitic ulcerations in the nos- 
trils, mouth, or elsewhere, that did not heal under their influence, unless 
.hindered by the presence of decayed bone. You may be ready to ask why 
.not give the biniodide of mercury ready formed, as the iodide of sodium 
and bichloride are supposed to form the biniodide when combined in solu- 
tion. I answer, that if the combination is formed, there is left an efficient 
excess of the iodide of sodium in the formula, and that an abundant clin- 
ical experience has shown the two to be much more efficient than either 
one of the salts of iodine or mercury are alone. The combination given in 
the formula can be taken, by the great majority of patients, longer without 
affecting the gums or mouth, than either the proto or the biniodide of 
mercury, and with less impairment of the digestive and nutritive functions 
than the large doses of the iodide of potassium, which are so generally rec- 
ommended. Like all other active drugs, however, its effects should be 
carefully noted in each case, and the mercurial part of the prescription 
omitted whenever the gums or the breath show the mercurial impression; 
but may be cautiously resumed when these symptoms have disappeared. 
Strict attention should be given to hygienic and sanitary regulations; and 
patients should not be allowed to continue a perpetual use of drugs, when 
there are no real appearances of disease, merely because they fear some 
form of trouble may come. With these brief and somewhat dogmatic 
statements I must leave the subject. 



RHEUMATISM. 291 



LECTUKE XXXI. 

Rheumatism— Its Varieties, Causes, Symptoms, Diagnosis, Special Pathology, Treatment, ami 
Prophylaxis. 

GENTLEMEN: I shall occupy your attention during the present hour with 
the consideration of one of the most common and most troublesome dis- 
eases that you will encounter in the field of general practice. I allude to 
rheumatism, which in its general application, includes a considerable vari- 
ety of painful and tedious affections. When cases present active general 
fever, associated with the local inflammation and swelling, they are called 
acuie rheumatism or rheumatic fever. When they present considerable 
local inflammation and swelling with but little general fever, they are 
often classed as sub-acute rheumatism. Cases presenting local pains, 
stiffness, and impairments of motion, persisting through considerable pe- 
riods of time, but without fever, are called chronic. Cases are also, by 
many, grouped and named from the structures prominently involved; as, 
myalgia, when located in the muscles; neuralgic rheumatism, when affect- 
ing the nerves or their sheaths; and other cases are named from the disease 
with wmich they may be associated, as syphilitic, gonorrhoeal, and gouty. 
This variety of grouping of cases and application of names, does not indi- 
cate any specific differences in the nature of the rheumatic affections, but 
simply differences in activity, location, or coincident morbid conditions. 
For accuracy of description and certainty of diagnosis, it is quite suffi- 
cient to arrange all cases in one or the other of two classes called acute and 
chronic rheumatism. 

Etiology. — The causes of rheumatism, in all its grades and forms, must 
be divided into predisposing and exciting. The first embrace all those in- 
fluences that are capable of increasing the excitability of the tissues on the 
one hand, and of retarding the cutaneous eliminations on the other. 

The most important of these are habitual exposure to frequent and se- 
vere atmospheric changes coupled with dampness, and protracted mental 
or physical labor. The influence of these causes in favoring the accumu- 
lation of an excess of lactic acid and lactates in the blood and secretions, 
and the localities in our country where they are most active, I explained 
sufficiently in a preceding lecture while commenting on the general eti- 
ology and pathology of the class of constitutional diseases.* Under the 
same head must be placed hereditary influences which were also explained 
in the preceding lecture. The chief exciting or direct cause of the local 
phenomena of rheumatism is an excess of such acid material in the system 
as is capable of inducing a specific grade of inflammation in some one or 
more of the fibrous tissues of the body. I say acid material, because in 
all the more acute forms of the disease, the blood and the several secre- 
tions have almost uniformly been found to contain more than the natural 
evidences of acidity, and the efficient neutralization of this by remedies 
has generally afforded relief. While careful and extensive analytical inves- 
tigations by different parties, have not shown conclusively the particular 
acid or acids present in excess, they have rendered it highly probable that it 
is chiefly lactic acid and its salts. Whatever may be the particular mate- 
ries morbi that constitutes the direct active agent in the production of 
rheumatic inflammation, its impression on the living tissues once made, 
leaves them ever afterward more susceptible to its influence than before. 

* See pages 252-3-4 of this work. 



292 RHEUMATISM. 

Tin's susceptibility is not merely local, thereby determining each new 
attack of inflammation to appear in the same articulations, but is so general 
that each successive outbreak is as likely to invade new structures or 
places as the old ones. This fact alone proves the constitutional or gen- 
eral character of the disease. Statistics show that all the forms of rheu- 
matism are most prevalent between the ages of fifteen and thirty years, 
yet they are sometimes met with at all periods from the first to the last 
year of human life. The acute and subacute grades are most prevalent in 
youth and the early part of adult life, while the chronic forms are more 
frequently associated with old age. The disease attacks a larger propor- 
tion of males than females; and is more prevalent among those engaged in 
physical labor than other classes, which is doubtless owing to their greater 
degree of exposure to the predisposing causes of the disease. 

Clinical History or Symptoms of Acute Articular Rheumatism. — The 
acute form of rheumatism, or rheumatic fever, varies much in its severity, ra- 
pidity of progress, and duration. The great majority of cases of average se- 
verity commence suddenly or with but little premonitory warning. The pa- 
tient often retires at night with only a little stiffness or slight feeling of sore- 
ness in his back. In some cases, this is so slight as to escape the patient's no- 
tice; while in others it is quite marked, either in the back or in some of the 
articulations. But he usually awakes before midnight with a severe ach- 
ing or gnawing pain in some part of the spine, or wherever the stiffness 
had been felt the previous evening. In attempting to change his position, 
he finds the pain greatly increased by every movement. Feeling fever- 
ish, restless and unable to leave his bed without intense suffering, he 
sends for his physican in the morning. The doctor, on his arrival, finds 
his patient with some redness or flush of the face; heat and dryness 
of the skin; a full and frequent pulse, generally between 90 and 100 
per minute; tongue covered with a thin white coat; urine scanty and 
high colored; bowels inactive; temperature in the axilla from 38.3° 
to 39°C (101° to 102.5° F.); with great restlessness from constant pains 
aggravated by motion. In other words he finds his patient presenting all 
the symptoms of an active irritative fever, to which are added the severe 
and constant local pains coupled with restlessness and yet inability to 
move without great increase of suffering, which is characteristic of acute 
rheumatism. In the most acute and severe form of the disease, the pain 
generally attacks the whole length of the spine at once, and in twenty- 
four hours it extends to the shoulders and hips; the next day it includes 
the elbows and knees, and by the end of the third or fourth day, it will have 
extended to the wrists, ankles, and small joints of the fingers and toes, 
thereby involving almost every articulation in the body and extremities. 
All the articulations attacked quickly become swollen, excessively tender 
to the touch, with constant aching pain much increased by the slightest 
motion. The swelling is generally diffused more or less over the whole 
joint, but is most prominent over the course of the ligaments, diminishes 
gradually in both directions from the articular junctions, having no ab- 
rupt margins or terminations, and presenting little or no redness on the 
surface. In the later stage of severe cases, the areolar tissue in the vi- 
cinity of the inflamed parts is often found infiltrate! with serum so as to 
pit more or less from pressure; and in some, the synovial membrane is 
sufficiently involved to cause serous effusion into the sac, which will make 
the most prominent part of the swelling between the ligaments crossing the 
joint, where there is the least resistance to the distension of the membrane. 
In the very severe cases I have been describing the disease generally reaches 
its acme, or highest stage of activity during the fourth or fifth days; when 



SYMPTOMS. 293 

the temperature is between 40° and 41° C. (104° and 106° F.); the puis,' 
full, and varying in frequency from 100 to 120 per minute; general scant- 
iness of secretion, especially of the urine, which is redder than natural and 
strongly acid in reaction with litmus, and the patient tortured with gnaw- 
ing pains throughout the trunk and extremities, yet utterly helpless from 
the increase of pain on every attempt to move. Having arrived at this 
stage of development, the natural tendency of the disease, when unmodi- 
fied by treatment, is to remain nearly stationary for three or four days, or 
until about the middle of the second week from the commencement of the 
attack. Of course during these days the loss of appetite, continued suffer- 
ing, and want of sleep, cause correspondingly increased weakness, with 
increased frequency and diminished force of the pulse; and sometimes, 
more especially during the night, some degree of delirium. During the 
last half of the second and the first half of the third weeks, the constant 
hard aching pains gradually disappear, leaving only soreness and pain on 
motion, with some swelling; the temperature gradually declines; the pulse 
becomes slower; the urine more abundant and often deposits on standing 
in the vessel, a red sediment; the skin becomes moist, and the patient takes 
short intervals of quiet sleep. These changes are pretty sure indications 
of a more rapid decline in all the general and local symptoms during the last 
half of the third week, and the establishment of convalescence as the pa- 
tient enters the fourth week of his confinement. In some few instances there 
has occurred during the last half of the second week a more copious dis- 
charge of urine, containing a large excess of saline and excretory constit- 
uents, with moderate spontaneous looseness of the bowels and moisture of 
the skin, followed by a rapid decline in all the general and local symp- 
toms of disease, and an early establishment of convalescence. On the 
other hand, a larger number of cases are met with, in which, after the 
middle of the second week the temperature remains high; the urine scanty, 
and though the skin becomes moist, the perspiration, even when quite 
free, has a sour disagreeable odor; the pulse becomes weaker and more 
frequent; the skin on the neck, upper part of the chest and axilla, cov- 
ered with sudamina; and by the end of the third week the wrists, back of 
the hands and feet are more or less cedematous, and the patient feels a 
great sense of exhaustion. Su3h cases usually prove very tedious, the full 
convalescence being postponed until the end of the fourth, fifth or even 
sixth week. And even then, in some cases, one or more of the articula- 
tions remain swollen, stiff, and sore for an indefinite period, the local in- 
flammation having assumed a chronic form. 

It is not often that acute rheumatic inflammation attacks internal or- 
gans or structures, except the heart and its appendages. 

Inflammation of the interior lining of the left cavities of the heart and 
of the aorta, constituting rheumatic endocarditis, supervenes during the 
progress of a considerable percentage of the cases of acute rheumatism. 
Inflammation of the pericardium is next in the order of frequency; while 
acute rheumatic inflammation of the membranes of the brain, the fiorous 
structure of the lungs, and the muscular coat of the stomach and intes- 
tines occurs very rarely. 

The fact that endocardial and pericardial inflammations frequently su- 
pervene as complications of acute rheumatic fever, should cause you to 
make direct examination of the condition of those organs every day during 
your attendance upon this class of patients. They may supervene at any 
stage of the general disease, but in the large majority of cases their pres- 
ence is first manifested during the second week of its progress. Their 
presence is readily detected by the more excited and fuller pulse; pain 



294 SUBACUTE KHEUMATISM. 

and oppression in the cardiac region, and especially by the characteristic 
bellows murmur from the endocardium, and friction sounds from tne peri- 
cardium. The occurrence of either or both of these complications during 
the progress of a case of rheumatism, adds much to its gravity, and gen- 
erally increases much the duration of the patient's sickness, though seldom 
causing a directly fatal result. 

From the description I have given you of the more active grades oi 
acute rheumatism you will infer that the disease, though varying much in 
i*"s severity and duration, generally tends toward recovery in from two to 
six weeks. 

Subacute Rheumatism. — In a large proportion of the rheumatic at- 
tacks met with in general practice, the symptoms commence less abruptly 
and the febrile phenomena are much less severe throughout their course. 
After feeling some stiffness and soreness, either in the upper part of the 
dorsal or in the lumbar part of the spine for one, two or three days, the 
patient finds it difficult to get out of bed on account of an increase of such 
stiffness, accompanied by continuous dull pain and a moderate fever. 

The local pain usually increases moderately for about three days, when 
it quickly declines. But simultaneously with such decline, if it had been 
in the lower part of the back and hips, it commences in the knees and 
steadily increases with some swelling and tenderness, for three days, when 
it moves to the ankles, and after about the same length of time, it moves to 
the smaller joints of the feet and toes. If the attack has commenced in the 
neck and shoulders, it will tarry the same length of time, presenting the same 
symptoms, and then move successively to the elbows, wrists, and smaller 
joints of the hands and fingers. Occasionally a case occurs in which the 
local inflammation attacks parallel articulations in both upper and lower 
extremities simultaneously. While in a large majority of the subacute 
cases the local symptoms commence in some part of the spine and move 
from one series of articulations to another, in the direction of the feet and 
hands, I have seen cases in which this order was reversed, the smaller 
joints being attacked first, and the larger ones in successive order until 
the spinal column was reached. In a large majority of cases the local inflam- 
mation moves bilaterally; that is, it attacks corresponding articulations on 
both sides at the same time. This is not always the case, however, for I 
have seen many of the milder grade, in which the disease attacked in suc- 
cession all the joints of one arm or one leg, and then those of the other. 
But it is exceeding rare that true rheumatic inflammation limits its attack 
to a single articulation, either in the trunk of the body or extremities. 

It is generally the subacute grade of rheumatism that sometimes at- 
tacks the muscles or the fascia surrounding them, and their tendinous 
attachments, technically called myalgia. 

The muscular structures most frequently involved are those of the loins, 
shoulders, diaphragm, intercostals, and the muscular coat of the intestines. 
It is the same grade of the disease that so frequently involves the spinal 
nerves at their exit from the spinal column, particularly the roots of the 
sciatic and the intercostals, causing severe neuralgic pains throughout the 
whole distribution of those nerves. It is also the subacute form of rheu- 
matism that is apt to attack patients suffering from gonorrhoea, and it is 
then called gonorrhceal rheumatism. 

In this connection it is limited to no class of structures, but is most 
frequently met with in the wrists and ankles and the smaller joints of the 
extremities, where it often persists for a longtime, and in some cases per- 
manently impairs the usefulness of the parts either by inducing adhesions 
of the tendons to their sheaths, causing a form of false anchylosis, or by 



CHRONIC RHEUMATISM. 295 

such a degree of softening of the ligaments and fibrous structures, as make 
the joints loose, flabby, and too weak for use. As rheumatic gout is a 
mingling of some of the phenomena of both gout and rheumatism, I 
shall defer any special description of it until the phenomena of gout have 
been under consideration. 

Chronic Rheumatism. — Chronic rheumatism may be a sequel of the 
acute or subacute varieties or it may originate in a chronic form without 
having been preceded by any more active stage. When it follows a more 
acute attack, some of the articulations that were primarily affected, re- 
main more or less stiff, and the ligaments sufficiently thickened to make 
the parts appear slightly swollen. The stiffness and soreness is most 
marked on first rising iii the morning, or in commencing motion after a 
period of rest, but diminishes while the exercise is continued, so that 
many who are hardly able to dress themselves in the morning, after get- 
ting started, do a fair day's work every day. They are exceedingly 
sensitive to atmospheric changes, being generally comfortable during 
warm and dry weather, but suffering much increase of lameness and pain, 
especially during the night, with every recurrence of cold and damp. 
They are also very liable to a renewal of more acute attacks, especially 
during the variable weather of spring and autumn. Cases of rheumatism 
that are chronic, ab initio, are chiefly met with among the laboring classes 
of both sexes. Washing and scrubbing women, and those men who are 
engaged in such manual labor as exposes them much to cold and wet, 
furnish a laro-e portion of all the cases of strictly chronic rheumatism. 
The disease may commence in the muscular and ligamentous structures 
in any part of the body or extremities, but is much the most frequent in 
the lower part of the back and hips, in the shoulders, in the wrists and 
smaller joints of the hands, and in the ankles. It usually commences 
with dull aching pains during the night, followed by some sense of stiff- 
ness and soreness in the morning, which mostly disappears after a little 
exercise, but returns in the same manner when night comes. At first 
the symptoms continue only a few days at a time, which is generally dur- 
ing wet and cold weather, or after unusually severe exercise, and disap- 
pear while it is mild and dry. Each succeeding year, however, the 
periods of suffering become more protracted and severe; and the patient 
finally becomes a more delicate indicator of the electric and hygrometric 
conditions of the atmosphere than any instruments hitherto devised. The 
ligaments and fibrous structure of the articulations most affected, become 
gradually thickened or hypertophied and hardened, causing the joints to 
appear enlarged as well as stiff, and much of the time, painful. 

This is particularly true concerning the wrists and the smaller joints of 
the hands and fingers, which sometimes become so stiff that they can be 
neither fully flexed nor extended, and consequently their usefulness is 
very much impaired. And yet, most of these patients are exempt from all 
general febrile symptoms, retaining a fair appetite, a good degree of nutri- 
tion, and a general feeling of health. 

Sometimes they are troubled with constipation, sour eructations, acid 
urine, and some degree of general muscular atrophy. The latter, by 
shortening the muscles, causes more flexure of the joints and more deform- 
ity of the extremities. I have seen several old cases of this kind, in which 
the patients could neither get a hand to their heads, feed themselves, nor 
walk. Purely chronic rheumatism seldom invades the internal organs and 
structures of the body, and consequently manifests but little tendency to 
shorten the duration of life. If there are any exceptions to this rule, they 
relate chiefly to the fibrous tissues of the bronchial tubes, the uterus, and 
the bladder. 



296 CHRONIC RHEUMATISM. 

I have long been satisfied that many of the habitually recurring cases of 
chronic capillary bronchitis, and of a similar grade of morbid action in the 
connective tissue of the lungs leading to what has, by some, been called 
fibroid phthisis, are strictly rheumatic in their nature. The same is true of 
the fibrous structure of the uterus in many of the cases of dysmenorrhea 
and habitual aching in the back and hips; and of the bladder in some of the 
cases called cystitis and irritable bladder. But the special features of all 
such cases are more conveniently considered in connection with the local 
affections of those organs. 

Diagnosis. — The symptoms and progress of acute and subacute rheu- 
matism are, in several respects, so peculiar as to leave very little liability 
to error in regard to diagnosis. The movable or migratory character of 
the local inflammation, the involvement of corresponding articulations on 
each side at the same time, the absence of all tendency to suppuration, and 
the character of the accompanying fever, are sufficient to distinguish all 
ordinary cases from other affections. The diseases most likely to be con- 
founded with rheumatism, are acute and chronic synovitis, periostitis, 
gout, and some cases of pysemia. If you remember that the two first are 
fixed, not movable from one part to another, and generally accompanied 
by some degree of serous effusion into the synovial sac, that periostitis 
commences on the shaft of the bones between the articular extremities, 
and that both gout and pygemia have characteristic antecedent histories, 
you will readily avoid mistaking either of these for any grade of rheuma- 
tism. There is more danger of mistaking rheumatic inflammation of the 
diaphragm and intercostal muscles for pleurisy or hepatitis, or that of the 
muscular coat of the intestines for peritonitis. The more dull and con- 
tinuous character of the pain, and the absence of either pleuritic friction 
or diminished resonance above the diaphragm, and equallv, absence of the 
physical signs of enlargement of either liver or spleen below, will remove 
all doubts in regard to rheumatism in the lower part of the chest and 
diaphragm. While in the abdomen, the co-existence of dull pain, much 
increased by peristaltic motion of the bowels, only moderate tenderness to 
pressure, moderate general fever, constipation, scantiness and increased 
acidity of the urine, and the persistence of these from day to day with 
but little distension of the abdomen, and no effusion into the peritoneal 
sac, differs so much from the more acute pain, quicker pulse, higher tem- 
perature, greater tenderness and earlier abdominal distension of peritoni- 
tis, that the one should not be mistaken for the other by any of you. 

The diagnosis between chronic rheumatism and neuralgia rests mainly 
on the fact that the pain in the first is dull and aching, and located 
chiefly in the muscular and ligamentous structures; while that of neuralgia 
is sharp, intermitting, and located in the course of some one or more 
nerves. The first is most stiff and painful at the beginning of motion, 
and often disappears during its continuance, while the lattei is either un- 
affected by motion, or it increases with the continuance of the movements 
in the part which is the seat of pain. 

Prognosis. — The prognosis in all forms and stages of rheumatism is 
favorable, so far as relates to the continuance of life. In some of the most 
acute attacks, unmodified by treatment, the long continuance of extreme 
pyrexia, or very high temperature, causes great prostration, and doubtless 
in some rare instances, terminates fatally, without the extension of the 
local inflammation to important internal organs. But no such case has 
come directly under my own observation. When the attacks become 
complicated with acute rheumatic inflammation of the cerebral, pulmonary, 
or cardiac structures, there is more danger, and fatal results are much 
more frequent. 



TREATMENT. 297 

Fet, far the larger proportion even of these complicated cases recover from 
the acute stage of the disease, but with thickened and hardened cardiac 
valves, pericardial adhesions or sclerosis of the connective tissue of the 
lungs, which, in the remote changes they induce, ultimately lead to a 
materia] shortening of the period of life. 

Spt cial Pathology^ and Pathological Anatomy. — In the lecture on the 
general pathology of the class of constitutional diseases, I stated that the 
essential pathology of rheumatism consisted in an increase or exaltation of 
the elementary properties of the tissues; an increase of the plasticity of 
the blood, resulting from the accumulation of certain acid products (prob- 
ably lactates) in the system; with a strong tendency to develop local 
sthenic or plastic inflammation in the fibrous structures of the body and 
extremities. That these views are correct, both in regard to the general 
rheumatic diathesis and the special characters of the local inflammations 
accompanying it, is rendered more evident by the nature of the structural 
changes that are found to have taken place in the inflamed tissues. There is 
literally no tendency in rheumatic inflammation to purulent degeneration of 
the exudative material or to the establishment of the suppurative process. 
On the contrary the exudative material rapidly acquires a low grade 
of organization, increasing the bulk and density of the inflamed 
structures, and in many instances becomes so fully identified with the nat- 
ural structure as to disintegrate and disappear very slowly after convales- 
cence; and in some cases, even remaining permanent, as in the thickened 
and indurated cardiac valves, the hypertrophied ligaments over the affect- 
ed articulations, and the firm adhesions in the pericardium, sheaths of the 
tendons, synovial membranes, etc. In no other form of disease do we 
find inflammation presenting a character so persistently plastic as in rheu- 
matism. 

Aside from the evidences of increased acidity in the blood and secretions, 
the most notable changes in the first named fluid are the great increase 
of fibrin, and moderate decrease in the red corpuscles, albumen, and sol- 
uble salts. These changes are most notable in the more severe grades of 
the acute form of rheumatism, while in the subacute and chronic forms 
they are very slight. 

Treatment. — In the treatment of acute rheumatic fever and inflammation, 
the practitioner has four distinct indications to be fulfilled, or well defined 
purposes to be accomplished. 

1st. To neutralize the excess of acidity which is supposed to constitute 
the immediate cause of the febrile and inflammatory actions. 

2nd. To promote the eliminations, more especially from the skin and 
kidneys for the purpose of preventing further accumulation, in the system, 
of the same offending material. 

3rd. To alleviate the suffering of the patient by such sedative and ano- 
dyne remedies as will lessen the morbid excitement in the nervous and vas- 
cular structures. 

4th. To so far lessen the plasticity of the exudative material that it will 
undergo early disintegration and removal from the tissues ; thereby pre- 
venting those hypertrophies and indurations which are so prone to result 
in permanent cardiac changes, and such stiffness as to permanently im- 
pair the usefulness of many of the articulations. 

The first and second of these indications are founded on the idea that 
the disease depends upon the presence of a material cause, and have for 
their object its destruction or removal, so far, at least, as to suspend its 
further influence in the system. 

The third and fourth relate to the modification or removal of the morbid 



298 RHEUMATISM. 

processes already established. The means for fulfilling these several in- 
dications may be numerous and varied in their nature; but the indications 
themselves, being founded upon the assumption of an efficient cause and 
the nature of the morbid actions it induces, will always remain the same. 

Although each of the indications named presents a well defined purpose 
which should be clearly comprehended by the practitioner, yet, as often 
happens in the treatment of acute diseases, especially in the early stage, 
the same remedies that efficiently fulfill the indications for the removal of 
the exciting cause or causes, also fulfill, at the same time, all the others. 

That is, an early removal of the efficient cause, is directly followed by 
a disappearance of its effects. This is not always the case, however; for 
when inflammatory action has continued until more or less exudation has 
taken place, and the blood has become impregnated with an excess of 
fibrin and other products of tissue changes, it will often continue through 
its remaining stages after the further action of the exciting cause has en- 
tirely ceased. In acute and subacute rheumatism the first object is to 
impregnate the blood and tissues with such quantity of alkaline salts as 
will fully neutralize the excess of acid material, and render the urinary 
secretion either neutral or alkaline in its reaction. For this purpose alone 
we have no better remedies than the carbonates and bicarbonates of sodium 
and potassium, given dissolved in water, in as large and frequently re- 
peated doses as the stomach will tolerate until the desired saturation is 
obtained. From one to three grams (gr. xv to gr. xlv) given every 
one or two hours will generally produce the desired effect in neutralizing 
the acidity in from one to three days; after which the same doses may be 
continued at longer intervals. This same saturation of the blood with 
alkaline salts, constitutes one of the most efficient means for lessening the 
plasticity of the exudation taking place in the inflamed structures; and 
consequently helps to fulfill the fourth indication that I named to you. 
To promote the action of the skin, kidneys, and glandular structures gen- 
erally, and at the same time lessen the suffering of the oatient, it was 
formerly the practice to give a combination of the compound powder of 
ipecacuanha and opium with nitrate of potassium and small doses of calo- 
mel, every four or six hours until the intensity of the disease abated. 
During the last few years it has been ascertained, both by experiments on 
animals and by abundant clinical observation, that the salicylic acid, in 
efficient doses, produces a strong sedative effect on the sensory and ex- 
cito-motory nervous system and lessens the temperature as an antipyretic. 
These properties give it the power to speedily relieve the intense suffering 
and high temperature of acute articular rheumatism; and when combined 
with a carbonate or bicarbonate of sodium, its administration fulfills all 
the indications presented in the early stage of the more acute and severe 
grades of rheumatic disease. You may combine it with the alkaline salt 
extempore, or better perhaps use the officinal salicylate of sodium, of 
which from six to ten decigrams (gr. x. to gr xv), may be given, in dilute so- 
lution in water, every one or two hours until the pain and fever abate; 
then double the interval between the doses and continue it until all pain 
and fever have ceased. I have seen many cases during the last four or five 
years, both in hospital and private practice, in which the salicylate of sodi- 
um thus administered, produced entire relief from pain and fever in from 
one to three days. Then by lengthening the interval between the doses 
just sufficient to perpetuate the influence gained for three or four days 
more, with a laxative when needed, and from three to five decigrams of qui- 
nine three times a day, convalescence has been well established, in from 
five to seven days from the commencement of the attack. It is only in 



TREATMENT. 299 

the acute form of the disease accompanied by an active grade of fever, 
that 1 have found the salicylate to act so promptly beneficial. And even 
in these, if. from neglect or otherwise, the disease has already progressed 
to the middle or latter part of the second week and presents a small fre- 
quent pulse, a skin bathed in a sour perspiration; scanty urine: and a de- 
cided sense of weakness, I have found the salicylate too strongly sedative; 
and have obtained much better results from sub-nitrate of bismuth, bi- 
carbonate of soda, and quinine; the two first, in doses of six decigrams 
fgr. x) and the last, two decigrams (gr. iii), given every three hours until 
relief is obtained. At the same time I have derived additional benefit 
by giving fair doses of the tincture of digitalis to lessen the cardiac irrita- 
bility and promote the action of the kidneys. It is in this same condition 
of debility with unhealthy perspiration, that the tincture of chloride of 
iron has been found beneficial. 

If either endocardial or pericardial symptoms supervene in any stage of 
acute rheumatic attacks, I continue vigorously the same remedies for the 
general rheumatic disease, as in other cases, but give in addition alterative 
doses of calomel every four hours until there is a slight mercurial odor in 
the breath, and such doses of the tincture of veratrura viride as will aid in 
controlling the excess of cardiac excitement. If effusion takes place into 
the pericardium, or the endocardial bellows sounds continue after the cli- 
max of the fever has passed, a blister over the cardiac region will do 
much good; and a continuance of fair doses of the iodide of potassium 
in conjunction with digitalis for a considerable time after the slight mercu- 
lial impression has been induced, will add to the probability of preventing 
any permanent induration or thickening of the cardiac valves, which is a 
matter of great importance in all these cases. 

In the various grades of subacute rheumatism, the several indications 
for treatment are the same as in the acute, and the remedies to be used 
substantially the same, but they need not be used with the same degree 
of activity. 

When either the acute or subacute grades of rheumatism prove unu- 
sually persistent, and notwithstanding the thorough use of alkaline salts, sal- 
icylate sodium, quinine and anodynes with light mercurial alteratives, some 
of the articulations remain swollen, tender to pressure and motion, with 
an irritable pulse, restless nights, rather scanty and high-colored urine, 
though not much fever or elevation of temperature, you may know that 
the disease is strongly disposed to assume a chronic form. Many such 
cases will get almost convalescent, and then be renewed moderately, with 
every noticeable change in the atmospheric conditions. In such cases I 
have found certain vegetable remedies of much value, more particularly 
the cimicifuga racemosa, phytolacca decandra, and the senecio aureus. 
They may be conveniently used either in the form of tincture or fluid ex- 
tract. J have used them chiefly in the latter form, and in combination 
with stramonium and some saline diuretic. 

The following is a convenient formula: 

^ Potassii Acetatis 15. grams 3iv 

Extracti Phytolacca Dec. Fluidi 60. c. c. §ii 

Tincturae Stramonii 15. " 3iv 

Elixer Simplicis 45. " fiss 

Mix, and give four cubic centimeters (fl 3i) every six hours, in a little 
additional water. The cimicifuga or the senecio may be substituted for 
the phytolacca in the same proportion to the other ingredients. When 
the case requires a constant prompting of the action of the kidneys, bow- 



300 KHEUMATISM. 

els and secretory structures generally, I think the phytolacca decandra the 
most efficient. But if the bowels and secretions are free, and the fibrous 
tissues, including the cardiac structures, are especially irritable, the 
cimicifuga or the senecio aureus are preferable. 

To get the full beneficial effects of either of these remedies, their use 
must be continued several weeks. In cases having any of the elements of 
gout, either hereditary or acquired, I have found much benefit from the 
administration of colchicum. 

The wine of colchicum root maybe added in proper proportion to the for- 
mula just given, or it may be given separately in doses of one cubic centi- 
meter (min. xv) three or four times per day. In cases involving either 
syphilitic or gonorrhoeal influences, the iodide of potassium maybe substi- 
tuted in the place of the acetate with much advantage. 

The successful management of cases of purely chronic rheumatism, is a 
matter of great difficulty. This is owing in part to the fajt that a very 
large proportion of such cases occur among the laboring classes, and in in- 
dividuals who can neither afford to separate themselves from further expos- 
ure to the predisposing and exciting c .uses of the disease, nor be induced 
to adopt such measures, habitually, as would best protect them from the 
effects of such further exposures. Consequently they generally call for the 
aid of the physician only when they are suffering some exacerbation of 
their symptoms, and cease to heed his directions as soon as such special 
exacerbation has passed. When you are called to prescribe for these 
chronic cases on account of some fresh increase of the symptoms, I know 
of no remedies for internal use that will be more likely to relieve 
them than such as I have just mentioned for cases that are passing 
from a more acute to the chronic form. If the fresh aggravation of 
symptoms has been sufficiently severe to make the patient feverish, with 
coated tongue and dry skin, it will often render relief more certain if in 
addition to other remedies, you give the first night five or six decigrams 
(gr. viii or x) of Dover's powder with two decigrams (gr. iii) of calomel, 
and follow with a saline laxative in the morning. For permanent relief 
from chronic rheumatism, we must aim to maintain, continuously, a 
healthy and natural action of all those organs and structures concerned in 
the work of eliminating the products of tissue changes and other waste 
and foreign material from the blood. The means for doing this are chief- 
ly hygienic rather than medicinal. To lessen the effects of sudden and 
severe atmospheric changes, underclothes of flannel or other non-conduct- 
ors of heat and electricity must be habitually worn next to the skin; 
damp and uncomfortably cold rooms must be avoided both during the day 
and the night; both physical and mental exercise should be as uniform as 
possible, avoiding the extremes of close confinement on the one hand, 
and of excessive or protracted exercise on the other; the diet should be 
plain, nutritious, sufficient in quantity and variety to furnish all the ele- 
ments necessary for healthy nutrition and taken at the regular meal times; 
and the drinks should be such as do not, either retard molecular changes 
in the blood and tissues, or lessen important excretory functions. Good 
water, milk in any form, and weak tea and coffee may be allowed in any 
quantity the patient may desire. Strong tea and coffee used freely, in- 
creases the excitability of the nervous system and lessens the appetite for 
nutritious food, and had better be avoided. And all forms of alcoholic 
drinks, whether fermented or distilled, lessen molecular changes and the 
elimination of excretory material, and consequently favor the accumula- 
tion of such material in the blood and tissues. Their effects, therefore, 
are positively detrimental in the rheumatic as well as in the gouty diathe- 



TREATMENT. 301 

sis. In addition to all these hygienic measures, a warm alkaline bath may 
In* taken once or twice per week, especially in such cases as present an 
unusually dry skin. From 240 to 3(i0 grams (3 viii to ^X-ii) of carbonate of 
sodium may be put into an ordinary bath tub of comfortably warm water, 
in which the patient may remain immersed from five to eight minutes. 

On rising from the bath the water should be wiped off with towels, and 
the whole surface briskly but lightly rubbed with dry, soft flannel, which 
brings a very pleasant glow of electric warmth to the surface, and greatly 
promotes the healthy function of the skin. The best and safest time for 
the bath is just before retiring to bed for the night. In some cases of 
long standing, in which the bowels are habitually costive, and the diges- 
tion of food somewhat impaired, I have found the following pills capable 
of affording much relief from the constipation, and at the same time, of 
lessening the rheumatic pains and soreness: 

5 Ferri Sulphatis . 3.0 grams, gr. xlv 

Extract! Colchici Acetici 1.5 " " xxii 

Extracti Cannabis Indicas 1.0 " " xv 

Extracti Stramonii 0.6 " " x 

Pulervis Aloes 0.6 " " x 

Mix; divide into xlv pills, of which one maybe given before each meal- 
time until the bowels become regularly moved once a day. Then the 
one before dinner may be omitted, and generally one week later, another 
may be omitted, leaving but one pill every night, which often proves suf- 
ficient to keep the digestive organs and alimentary canal in a strictly 
regular and healthy condition, and the patient comparatively comfortable. 
In another class of cases, you will find not. only habitual constipation and 
flatulency, but also considerable spansemia or impoverishment of the 
blood, with cold extremities. 

In such, thirteen centigrams (gr. ii) of gum guaiac may be added to 
each of the pills just mentioned, in the place of the extract of colchicum. 
I might detail to you a great variety of additional remedies that have been 
used with more or less benefit in different forms and stages of rheumatism; 
but if I have enabled you to see clearly the objects to be accomplished, a 
proper knowledge of your materia medico, will furnish you an ample 
number of remedial agents from which to choose. Consequently, I will 
detain you for only one further suggestion. In all cases where the cir- 
cumstances of the patient will permit, a permanent change from a resi- 
dence in a cold, damp and variable climate, to one that is mild and dry, 
will be the surest mode of obtaining permanent relief. Of course, even 
this will not restore those old cases of chronic deformity from hypertrophy 
and induration of ligaments, tendinous adhesions, and atrophied muscles; 
but those in which the morbid changes are less structural, or more recent, 
great benefit may be derived from the change. So, where the rheumatic 
diathesis is strong, temporarily residing in a mild and dry climate during 
the most wet and variable parts of each year, will often enable the indi- 
vidual to avoid attacks from which he would otherwise suffer. Mineral 
waters containing a large proportion of the alkaline carbonates, may also 
be used with advantage in many cases, both for drinking and warm 
bathing. 



302 GOUT. 



LECTURE XXXII. 

Gout— Its History, Causes, Symptoms, Morbid Anatomy, Diagnosis, Prognosis, Treatment and 
Prophylaxis. 

GENTLEMEN: The disease to which I shall invite your attention dur- 
ing the present hour, is not one that you will meet often in the ordi- 
nary field of practice outside of the older cities of our country. Podagra, 
arthritis, or gout, as the disease has been called by different writers, is pre- 
eminently an affection originating in the midst of civilization and luxury. 
It was recognized and accurately described by the earlier medical writers, 
though not always differentiated from rheumatism with which it has some 
symptoms in common. The word gout, and all the other names applied to 
the disease, relate to an affection accompanied by deposits in or about the 
joints, and consequently is suggestive of a mere local disease. But like 
rheumatism, it always involves more or less alteration of the properties of 
the tissues generally, in such a way as to give the individual a constant 
and strong tendency to develop certain local morbid phenomena on the 
occurrence of any exciting cause. When this alteration in the properties 
of the tissues or general constitutional condition is once established, it is 
seldom entirely removed, and is readily transmitted to the offspring. 

Causes. — Both the predisposing and exciting causes of gout are well 
understood. The former consist chiefly of hereditary influence, the habit- 
ual use of rich food, fermented alcoholic drinks, and very little outdoor 
exercise. The coincidence of the three last influences without the first, 
if continued for several years, is sufficient to develop the disease in any 
of its active forms. But they will induce the same result much earlier 
and more readily if the hereditary predisposition aleady exists. 

The free use of meats and other nutritious articles of food, requires for 
their proper disposition in the human system, a conicident full supply of 
oxygen to the blood as it passes through the lungs, and an active state of 
all the excretory or eliminative functions. You are all familiar with the 
physiological fact that all eliminations are increased by physical exercise 
and diminished by rest. And no fact is better established than that the 
presence of a small quantity of alcohol in the blood, such as is supplied 
by a moderate daily use of beers and wines, decidedly diminishes both 
the oxygenation and decarbonization of the blood as it passes the air cells 
of the lungs. It is plain, therefore, that if the supply of new material 
through the digestive organs continues abundant while the supply of ox- 
ygen through the lungs and the activity of the excretory processes are 
both diminished by a daily moderate supply of alcohol from fermented 
drinks and too little physical exercise, we shall necessarily have retained 
in the blood and tissues an excess of materials that should have been fur- 
ther oxidized and eliminated. The habitual presence of this excess of 
materials, so alters the properties governing the molecular movements, as 
to result in the final establishment of a morbid constitutional condition 
or diathesis, and the development from time to time of the active local 
phenomena of gout. 

From the investigations of Dr. Garrod and others, it appears well as- 
certained that the prolonged opsration of the causes I have just detailed 
finally results in the accumulation, in the serum of the blood, of a large 
excess of uric acid and urate of sodium, which become the direct exciting 
causes of the local development of acute and chronic gout. When a well 
marked gouty diathesis has been inherited, the individual may suffer from 



CAUSES. 303 



the neuralgic and other chronic forms of gout, without any personal errors 
of diet or modes of living; and even acute attacks may be produced in 
such by sedentary habits and free indulgence at the table, without any 
use of alcoholic drinks. 

But 1 doubt whether the disease is ever produced, cle novo, in persons 
having no previous hereditary tendency, without the habitual use of some 
variety of alcoholic drink. 

As you will infer from what I have said concerning the predisposing 
causes of gout, the active forms of the disease seldom occur until near the 
middle period of adult age. It is also much more frequently met with in 
males than females. The disease prevails most in countries and commu- 
nities where the social habits of the people lead to the daily moderate use 
o( wines and malt liquors, with comparatively little of the distilled spirits. 
The tree use of the stronger liquors, as whisky, brandy, rum and gin, leads 
more directly to functional and structural diseases of the stomach, liver 
and kidneys, and seldom develops the gouty diathesis. But the efficiency 
of the fermented drinks, in producing the disease, appears to be in direct 
proportion to the percentage of alcohol they contain. For a very inter- 
esting illustration of the effects of social and hygienic habits on the pro- 
duction of diseases, including all the varieties of gout, I refer you to the 
chapter in one of the volumes of " Medical Inquiries and Observations," 
by Dr. Benj. Rush, in which he compares the social customs and diseases 
prevalent in Philadelphia during the ten years preceding the commence- 
ment of the War for Independence in 1775, with those of the ten years 
following the close of that war in 1782. 

Where the diathesis or constitutional condition already exists, an acute 
attack or paroxysm of local gouty irritation may be induced by a variety 
of temporary exciting causes, as severe and protracted mental application 
or anxiety; undue physical exercise, or exposure to cold and wet; and ex- 
cesses in eating and drinking. Working in contact with lead is thought 
to favor the development of the disease. It is more prevalent in the tem- 
perate than in either the tropical or the more extreme cold climates. It is 
much more prevalent in the older cities in the eastern part of our country 
than in those of the western. The difference, however, is owing much 
more to the differences in the social habits of the various communities and 
nations than to any influence of climate or topography. During an active 
practice of more than thirty years in this city 1 have seen but very few 
cases of gout, except in persons who had a plain hereditary predisposition, 
or had brought the disease with them from some older communitv. 

Clinical History or Symptoms. — The cases of gout, as they are met with 
by the physician, may be grouped for convenience of description under 
the familiar names of acute and chronic. An attack of acute or transient 
gout is generally sudden, and often without warning, although in many 
cases the patient has been suffering for the two or three preceding days 
from indigestion, flatulence, mental depression or irritability of temper, 
etc. And sometimes an attack comes as the direct result of one or two 
days or evenings of excessive debauchery. The acute symptoms usually 
commence during the middle or last part of the night, and consist of a 
severe pain in some one of the joints, most frequently in the proximal 
joint of one of the large toes, coincidently with first, slight chilliness, and 
subsequent quick development of general fever. The skin becomes hot 
and dry; face a little flushed; tongue often covered with a white fur; 
some thirst; pulse from 100 to 110 per minute and generally full; urine 



304 CHRONIC GOUT. 

scanty, high- colored, and deficient in uric acid; and general restless- 
ness. But the symptom that overshadows all others and occupies 
the entire attention of the patient, is the intense aching, gnawing 
pain in the toe, or whatever part is attacked with the inflammation. The 
articulation affected quickly becomes swollen, red upon the surface and 
most acutely sensitive to the touch and to the slightest motion. In the 
more acute and severe cases to which 1 am now alluding, both the local 
pain and general fever reach their highest intensity, in from two to four 
hours. After remaining nearly stationary for one or two hours more, they 
begin to decline. The patient becomes less restless, and sometimes has 
short intervals of sleep; and in from two to four hours more his fever and 
severe pains have disappeared, leaving him feeling weak and weary, with 
a continuance of the swelling, redness, and tenderness of the toe, but with 
little continuous pain. From this description you will see that an ordina- 
ry paroxysm may last from six to twelve or eighteen hours. On its sub- 
sidence the skin may become moist, the urinary secretion abundant, fol- 
lowed by a rapid diminution of both swelling and tenderness, and in two 
or three days the patient appears as well as usual. 

In a large proportion of cases, however, the subsidence of the active 
symptoms proves only a remission which continues until the middle of 
the following night, when another exacerbation begins, and presents the 
same symptoms, both local and general, as in the first. The paroxysms may 
continue thus to return every night, for a week or even longer, and in the 
meantime the local inflammation may have extended to all the articula- 
tions of the toes and sometimes to the ankle, or even to the articulations of 
the fingers and hands. In such protracted attacks, the patient becomes 
much more debilitated, the swelling and tenderness of the inflamed ar- 
ticulations, subside slower and less perfectly, with much more tendency 
to pass into the chronic form. Yet many of these more severe and pro- 
tracted attacks are recovered from so perfectly that in two or three weeks 
the patient feels more buoyant and in better health than for sometime be- 
fore the attack. But the susceptibility of the system to the disease in- 
creases with every new paroxysm, until such patients as have suffered 
several attacks, become subject to their recurrence from the slightest 
causes. 

In some cases the attacks are characterized by the same local pains, swell- 
ing, redness and extreme tenderness that I have described, but with much 
less general fever. These have been classed by some writers as subacute 
gout. • In some cases of both acute and subacute attacks, the inflamma- 
tion, after progressing a short time in the usual articulations, suddenly re- 
cedes, and is immediately manifested in some one of the internal organs, 
as the stomach, lungs, heart or brain; and with the rapid development of 
all the usual symptoms of acute inflammation of the organ attacked. 
Such cases are called retrocedent, or misplaced gout, and are very danger- 
ous to the life of the patient. Happily, they are not of very frequeut oc- 
currence. 

Chronic Gout. — The greater number of cases of chronic gout are the 
sequelge of acute attacks, and their local manifestations are of an inflamma- 
tory character. But more rarely cases are met with in persons of both 
sexes, which are characterized by periods of extreme pain without accom- 
panying inflammation, and without having been preceded by any acute 
inflammatory attacks. These cases are usually classed as neuralgic gout, 
and are probably met with only in persons having a strong hereditary pre- 
disposition. When after repeated attacks of acute arthritic inflammation, 
the affected articulations remain constantly more or less swollen, purplish- 



SYMPTOMS. 305 

red, tender to pressure, stiffened, and painful when motion is attempted, 
but without general fever, the disease is said to have assumed a chronic 
form; and may continue thus during the remainder of the patient's life. 
Such cases are subject to frequent temporary periods of increased activity 
with marked aggravation of the suffering ol the patient; sometimes from 
atmospheric changes, but more frequently from excesses in mental or 
physical labor and errors in diet and drink. Unless great care is exercised 
in avoiding all the causes that tend to increase the disease, the tendency 
of chronic cases is to gradually increase, both in the local developments 
and in the general impairment of health. The affected articulations be- 
come slowly increased in size, the tissues more indurated, and the joints 
less movable. This is owing in part to the sclerosis, or hypertrophy of the 
inflamed fibrous tissue composing the ligaments, synovial membranes, 
and connective tissues belonging to the affected articulations, and partly 
to the deposit of urate of sodium, calcium, etc., both into the cavity of the 
joints and into the surrounding tissues. In some cases of long duration, 
these deposits become so large as to cause, by their pressure, the absorp- 
tion of the soft parts covering them and the protrusion of naked inorganic 
crusts at the most prominent part of the articulations. 

While such external local changes are taking place from year to year, 
there are progressive internal changes of no less importance, that should 
receive your attention. In most cases the functions of digestion and 
assimilation become more impaired, as indicated by gaseous eructations, 
frequent turns of gastric acidity, and alternations of constipation and diar- 
rhoea, with progressive impoverishment of the red corpuscles of the blood. 
The urine becomes habitually scanty, and sometimes albuminous; the feet 
and ankles begin to show some cedematous infiltration while dependent 
during the day; a little exertion causes shortness of breath, palpitations, 
and sometimes faintness; and finally general dropsy supervenes, and the 
patient approaches near to the end of life. The final result may be 
reached in various ways. In some cases the general dropsical infiltrations 
simply continue to increase, with corresponding diminution of the urinary 
secretion; the mind becomes dull and somnolent; the breathing heavy 
and slow; pulse soft, irregular or intermitting; the whole exterior of face, 
body, and extremities much bloated from the dropsical infiltrations; finally, 
muscular twitchings, cold extremities, suppression of urine, irregular and 
stertorous respiration, entire coma and death supervene. In some cases, 
either from fatty degeneration or overwhelming pericardial effusion, death 
takes place more suddenly from failure of the heart's action. Or from a 
similar fatty degeneration of the coats of the arteries of the brain, some 
weakened vessel gives way, allowing hsemorrhagic exudation or extravasa- 
tion into the texture of the brain, and death by apoplexy or paralysis. In 
still other cases respiration is overwhelmed either by pulmonary oedema or 
pleuritic effusion. Such is a very brief description of the general course 
and terminations of chronic arthritic gout, when it proceeds to its own 
legitimate results. But patients subject to chronic gout, are more or less 
prone to intercurrent attacks of acute inflammation of important organs 
which often prove fatal before the gouty disease has reached the ultimate 
changes I have just described. 

Pneumonia, pleurisy, endo- and pericarditis, gastro-enteritis, and acute 
and chronic nephritis are among the most common intercurrent inflamma- 
tory affections to which gouty patients are subject. m 

The neuralgic form of chronic gout is less uniform in its characteristics, 
and more difficult to distinguish from other forms of neuralgia. It is usual- 
ly characterized by the sudden attack of very severe pain in some particu- 
20 



306 GOUT. 

lar part, without any premonition or warning, its unremitting continuance 
from one to six or eight hours without general febrile disturbance, and 
leaving the part without swelling or other visible changes. In some cases 
the patient endures but a single paroxysm of the pain; and in others it 
recurs at intervals of a few hours for several daj^s in succession. 

The locations most frequently the seat of pain, are the same as those 
most frequently attacked by inflammation in the acute form of the disease, 
namely the articulations of the toes and feet, those of the hands, and the 
stomach. One of the best characterized cases that has come under my 
observation, was that of a well-educated lady of most correct habits of 
life, but whose ancestors, through two or three generations, had suffered 
severely from gout. For several years she had been attacked two or three 
times a year, with the most excruciating pain in the proximal joint of the 
great toe. It usually came suddenly, without warning, and so severe as 
to render her entirely helpless while it lasted, which was usually six or 
eight hours, unless sooner relieved by remedies. The first occasion of my 
seeing her, she had been attacked with the pain while on the street, and 
had been obliged to have a carriage called to take her home. I recollect 
only three cases in which the epigastrium was the seat of pain. Two were 
males, and one a female of sedentary habits; and all belonged to families 
in which the hereditary gouty diathesis was strongly marked. 

Morbid Anatomy. — The changes that take place in the fluids and solids 
of the body in connection with gout, have been investigated with much 
care. The earliest and most marked change in the blood is the decided 
increase of uric acid and uric acid salts, particularly the urate 
of sodium. The existence of this excess of uric acid as a character- 
istic condition of the blood in acute gout was perhaps first suggested 
■by Murray Forbes, but not fully proved until the more valuable 
investigations of D •. Garrod, published in 1854. As the disease progresses, 
the red corpuscles and the albumen both fall below the natural proportion, 
while the fibrin is increased. For a few days before, and during the early 
stage of, an attack of gout, the urine has been found to contain less than 
its natural proportion of uric acid, and in some instances an increase of the 
phosphoric. In the structures constituting the seat of the local inflamma- 
tions in all stages of gout, there has constantly been found more or less 
deposition of urate of sodium, both in the form of acicular crystals and 
of granules. In recent cases these deposits appear in white lines or layers 
on the articular surfaces, and in the ligamentous and other tissues sur- 
rounding the affected joints. In older cases they accumulate in thicker 
layers or masses called tophi or concretions; and in such they are also 
found in many other parts of the body, more especially in the tubules of 
the kidneys, the sheaths of tendons and nerves, and in the membranes of 
the spinal cord. When the tophi or concretions in and about the joints 
become large, they usually contain, besides the urate of sodium, urates of 
magnesium and calcium, with more or less of the carbonate and phosphate 
of calcium. 

In many cases of long standing, the structure of the kidneys not only 
contains the uric acid deposits, but it has undergone more or less granular 
degeneration and atrophy, giving it the appearance of the small granular 
kidney of Bright's disease, and constituting the gouty kidney, of Dr. 
Todd. Waxy degeneration of the renal structure has also been observed 
in some cases; and in some, fatty and atheromatous changes have been 
found in the heart and in the coats of many of the arteries. The special 
pathology of acute and chronic gout is sufficiently indicated in the com- 
ments I have made on the causes, and morbid anatomy of the disease. 



DIAGNOSIS. 307 

Diagnosis. — The only diseases with which gout is liable to be con- 
founded are rheumatism, neuralgia, and rheumatoid arthritis. 

The difficulty chiefly relates to the earlier attacks of acute articular 
grout. If you keep in mind the facts that this variety of gout seldom 
occurs before thirty years of age, that it almost always attacks the small 
articulations of the extremities and very generally, first the proximal or 
metatarso-phalangeal joint of the great toe; that the pain is much more in- 
tense and aggravating, compared with the general febrile disturbance; 
that the tenderness is more acute and the redness deeper; and finally, 
that the patient's habits of life and perhaps hereditary predisposition, have 
been entirely different from those favoring the development of rheuma- 
tism, you will find but little difficulty in arriving at a correct diagnosis at 
once. If there remain doubts, however, you can obtain eight or ten cubic 
centimeters (fl 3ii or 3iiss) of the serum of the blood, either by scarifying 
and cupping, or by a blister, and apply to it any of the well-known tests 
for detecting uric acid or urate of sodium, the presence of which would 
confirm the diagnosis of gout. In chronic cases of articular gout, the 
simple clinical history of each case, with due attention to the present 
condition of the affected articulations, will be sufficient to establish a 
proper diagnosis. In neuralgic gout the diagnosis must be determined 
mainly by the intensity and location of the pain, the time and 
manner of its recurrence, and the hereditary tendencies of the patient. Its 
differentiation from rheumatoid arthritis will be more appropriate after I 
have described that form of disease. 

Prognosis. — Except in the cases of retrocedent gout, in which some 
important internal organ has become the seat of the gouty inflammation, 
there is but little danger of a fatal result during- the acute stage of the dis- 
ease. Yet the gouty diathesis is seldom wholly removed by any method 
3f treatment that has been devised; and when the local inflammations have 
recurred many times, they are almost certain to induce a sufficient degree 
of structural changes in the kidneys and other important organs, to materi- 
ally shorten the duration of life. 

Treatment. — A proper knowledge of the causes and pathology of gout 
will suggest three distinct and important objects to be accomplished in 
its treatment; namely, the removal of the special exciting cause, supposed 
to be an excess of uric acid and urates, from the system; the alleviation or 
the intense suffering; and the prevention of the re-accumulation of the 
exciting cause for the purpose of avoiding a relapse or a new attack. 
The first of these objects may be accomplished by remedies that either 
neutralize the action of the uric acid and urate of sodium by forming new 
compounds with them, which are either harmless or more readily elimi- 
nated through the natural channels of excretion, or by such as rapidly di- 
minish their formation on the one hand, and increase their elimination by 
causing increased action of the skin and kidneys on the other. The par- 
ticular remedies that have been found by clinical experience to act most 
efficiently in the first direction, are the bicarbonate of potassium, carbonate, 
bromide and citrate of lithium, and phosphate of ammonium; while of those 
that act in the second direction, colchicum stands pre-eminent, having 
maintained its reputation undiminished from the earliest records of medi- 
cine in Greece and Rome to the present time. Recently jaborandi, from 
its known efficacy in producing copious diaphoresis, has been used in some 
cases and with decided advantage. To fulfill the second indication, by 
temporarily mitigating the intensity of the pain, the preparations of opi- 
um, especially when given in connection with colchicum, are by far the 
most effi3ientth.it we can use. Some effect miy ba produced by the use 



308 GOUT. 

of chloroform, hyoscyamus, belladonna, and aconite; but they are much 
less reliable than the opiates. The same may be said of the chloral hy- 
drate and the bromides. 

In the limited number of cases to which I have been called during the 
active paroxysms of acute or subacute gout, I have given promptly a 
combination of the wine of colchicum root, two parts, and the acetated 
tincture of opium one part, in doses of two or three cubic centimeters, 
(min. xxx or xlv) repeated, at first, in one or two hours until the pain and 
fever abated and then at longer intervals until the paroxysm had wholly 
subsided. In none of the cases coming under my own observation, has this 
combination failed to afford speedy and satisfactory relief from all the 
more active symptoms. There are cases, however, in which the opiates 
are promptly rejected by the stomach, or soon create much nausea and de- 
pression. In such cases I would substitute the bromide of liihium in the 
place of the opiate, in combination with colchicum. One of the benefits 
of combining an opiate with the colchicum, in addition to its effect in re- 
lieving pain, is the lessening of the tendency of full doses of the latter to 
operate harshly on the bowels before its specific effects are obtained in 
checking the production of uric acid and promoting its elimination. 
When it is found that the acute paroxysm has supervened while the bow- 
els were constipated or inactive, the tongue coated, and skin hot and dry, 
much benefit may be derived by giving at once five decigrams (gr. viK) 
of calomel and following it in tiree or four hours by sufficient Rochelle 
salts to cause two or three free evacuations from the bowels. This, how- 
ever, should not prevent or delay the use of the colchicum and opiate as 
already described. 

Recently some cases have been reported, in which liberal doses of the 
salicylates have been given, and apparently with prompt and satisfactory 
relief. If given in this disease, the salicylate of potassium is preferable 
to that of sodium, as the latter already exists in excess in combination 
with the uric acid, both in the bio *d and the inflamed tissues. When the 
acute paroxysm has been fairly relieved and the patient restored to a com- 
paratively comfortable condition, then, the means for fulfilling the third 
indication should be resorted to without unnecessary delay, in the hope of 
preventing the re-accumulation of the uric acid and urates in sufficient 
quantity to produce another paroxysm. This cannot be accomplished by 
any kind or amount of medication alone. Moderate doses of the wine of 
colchicum may be continued three times a day, either by itself or com- 
bined with the bromide or citrate of lithium, until the change in the diet, 
drinks, and exercise of the patient has had time to re-establish a healthy 
condition of the nutritive and excretory functions of the whole system. 
Particular attention should be given to the condition of the digestive or- 
gans, both in regard to the functions of the stomach and the regular evac- 
uation of the bowels. If the food lies heavy, feeling like a load or weight 
in the stomach and the bowels are costive, you may know that there is 
both deficiency in the gastric secretions and in the .peristaltic motion of 
the bowels. Some combination of a tonic and laxative will be needed for 
correcting these deficiencies. Perhaps none can be made better adapted 
to this purpose than the following: 



Extracti Hyoscyami 


2.0 


grams 


g r - 


XX 


Ferri Sulphatis 


2.0 


u 


u 


a 


Extracti Colocynthidis 


2.0 


tc 


(( 


C< 


" Nucis Vomicae 


0.6 


u 


a 


x, 


Pilulae Hydra rgyri 


0.6 


iC 


tc 


t< 



TREATMENT. 309 

Mix. Divide into thirty pills, one of which may be taken each night, or 
each night and morning, as found necessary to secure one regular evacu- 
ation each day. But whatever may be the kind of medicine administered, 
no permanent relief will be obtained unless a judicious and persistent reg- 
ulation of the diet, drinks, and exercise of the patient accompanies and 
follows it. The diet should consist chiefly of milk, farinaceous articles, 
vegetables and fruit, with meat only sparingly. Tea and coffee may be 
used moderately, but alcoholic drinks of every kind, whether fermented 
or distilled, should be entirely excluded from use. You will see it stated 
by authors of deservedly high reputation that the iceaker wines and small 
quantities of gin may be allowed, especially to patients who have long 
been habituated to their use, or have become much debilitated. With 
all proper deference to the opinions of others, I must caution you against 
such statements as conveying an important error. They are founded on 
the idea that alcohol in small quantities in the forms mentioned, helps to 
sustain the strength and nutrition of patients already habituated to their 
use and debilitated by attacks of gout or other forms of disease. From 
many years of observation and direct professional management of patients 
accustomed to the use of alcoholic drinks both in hospital and private prac- 
tice, I am satisfied that no form of those drinks can be made to act as a 
tonic or as a promoter of healthy nutrition. I have never known a pa- 
tient injured, or a life endangered, by stopping their use too suddenly, or 
abstaining from them too persistently. But I have known very many to be 
injured and finally lost, by persisting in the effort to use them moaerately. 
And the sooner a patient, predisposed to attacks of gout, omits entirely the 
use of all fermented or distilled drinks, the more readily will he make 
genuine progress in removing such predisposition, and in securing perma- 
nent exemption from new attacks. 

Another item of great importance in the management of these cases, is 
the proper regulation of the patient's exercise, both mental and physical. 
Whenever the patient is sufficiently free from acute symptoms to get out 
of the house, it is desirable that the mind should be occupied if possible by a 
few hours of daily attention to some light, cheerful business, that will serve 
to divert attention from himself and promote habitual action of the men- 
tal faculties. But all business involving protracted and severe mental ap- 
plication, anxiety or depression, should be avoided, so far as circumstances 
will permit. A certain amount of physical exercise in the open air is 
ol paramount importance. Riding, either in an open carriage or on horseback, 
walking when the joints will permit, or even engaging lightly in physical 
sports, should be resorted to daily, with as much regularity as in eating or 
sleeping. When these regulations cannot be secured at home, the patient 
should be encouraged to travel in mild climates, or visit and use those 
mineral springs, either in this country or in Europe, the waters of w r hich 
promote habitually increased elimination of effete matter through the 
urinary and cutaneous structures. 

The remedies, hygienic and medical, that I have mentioned as best cal- 
culated to prevent a repetition of acute attacks, are equally applicable in 
the treatment of all grades of chronic gout. When the latter form of the 
disease has been of long standing and the blood is much impoverished of 
its red corpuscles, with perhaps some oedema of the lower extremities, a 
moderate dose of citrate of iron and quinine taken after each meal-time, 
mav be found beneficial, as an aid to other remedies. 

When general dropsy has supervened accompanied by scanty and albu- 
minous urine, it very generally indicates such a degree of structural change 
in the kidneys as to render the prognosis altogether unfavorable. Palli- 



310 ARTHRITIS DEFORMANS. 

ation of symptoms and a rational effort to render the patient as comforta- 
ble as possible, will constitute the chief objects of treatment in such cases. 
When acute gout is misplaced or retrocedent, attacking important internal 
organs, it must be treated on the same principles, and, so far as the func- 
tions of the organ attacked will permit, by the same remedies, as in ordi- 
nary acute cases. 

You will occasionally meet with cases presenting an intermixture of the 
symptoms of gout and rheumatism; or with cases of rheumatism engrafted 
upon an inherited gouty constitution. Nearly all such cases can be most 
readily relieved by the judicious ur,e of the salicylate of sodium, combined 
with the wine of colchicum, or by a combination of the bromide of lithium 
with the alkaline carbonates, in conjunction with warm alkaline baths, and 
the same hygienic regulations as in similar grades of unmixed gout. 

ARTHRITIS DEFORMANS. 

This may be as convenient a time as will be likely to occur for saying a 
few words in relation to a disease called by some writers arthritis deform- 
ans, and by others rheumatoid arthritis; although it is doubtful whether it 
has any of the elements of gout in its nature. It occurs more frequently 
in women than in men, and chiefly in subjects who have been much ex- 
posed to physical hardship and mental cares or anxiety. It seldom 
occurs in childhood or youth, but is most frequent from the middle period 
of adult life to old age. It usually attacks first the larger joints, as the 
hip, knee, shoulder, and elbow, and extends subsequently to the smaller 
joints of the hands and feet. It does not attack many articulations at the 
same time, but commences in parallel joints on each side and extends 
symmetrically from one pair of joints to another progressively, until in some 
cases it has involved nearly all the articulations in both body and extrem- 
ities, and rendered the patients utterly helpless. The joints, when first 
attacked, present much the appearance of subacute rheumatism, being 
moderately swollen, tender, painful, especially on attempting motion, but 
with little or no general fever. In the earlv stage effusion of serum some- 
times takes place into the synovial membrane, increasing for a time the 
size and shape of the joints. This subsequently disappears and the syno- 
vial membranes generally become unnaturally dry and the joints stiff, or 
creaking from friction on motion. The pain is dull, aching in character, 
and increased by attempts to move the affected parts. Slowly those parts 
of the cartilages covering the articular surfaces of the bones that are sub- 
ject to direct pressure, become absorbed; sometimes to such an extent as 
to leave the surfaces of the bones naked in contact with each other. At 
the same time the edges of the cartilages become thickened irregularly, 
presenting hard nodules. The same thickening and induration take place 
in portions of the synovial membranes, periosteum and ligaments, making 
the joints appear large and irregular in shape. Occasionally a hard 
nodule will be formed in the mere projecting fringe that often appears on 
the edges of the articular cartilages, and will become detached and form 
a loose or floating cartilage in the joint. All these changes appear to 
consist of an increase or proliferation of the natural histological elements 
of the cartilaginous and fibrous tissues. In some cases phosphate of calcium 
or bony matter has been found in the more prominent nodules, but never 
the urates or chalky materials conni-on to gout. Neither has there been 
found an excess of uric acid or urates in the blood of this class of pa- 
tients. The changes I have described often cause much deformity 
especially in old people. The fingers and toes not only become 



TREATMENT. 311 

stiff, but turned in various directions, the former chiefly toward tho 
ulnar, and the latter toward the fibular side of the extremities. 
In a large proportion of the cases the muscles undergo more or lesa 
atrophy, ami the patients become pale and thin, though retaining a good 
appetite and fair digestion. Indeed there appears to be little or no tend- 
ency in this class of cases, to disease of either the cardiac, pulmonary, 
or digestive organs; and we consequently find the patients with the func- 
tions of all these organs well performed, who have been entirely helpless 
lor years, from the progressive and persistent morbid changes in the or- 
gans of locomotion. It is only a few days since I saw in the north part 
of the city, a woman about rifty years of age, mother of a Jarge family, 
who had lain in the condition just described between five and six years. 
Not one of her limbs could be straightened or moved sufficiently to get 
the bottom of a foot to the floor or a hand to her head. 

The special pathology of this class of cases is not well understood. 
That it is essentially different from either rheumatism or gout, is evident, 
both from their clinical history, and the nature of the structural changes 
developed during their progress. That the disease consists of a morbid 
increase of that property of the structures involved, which I have called 
susceptibility or irritability with a perversion of the affinity governing 
the movement of atoms, the symptoms and structural changes plainly show. 
But whether this alteration of the properties of the tissues results from 
the presence of some retained morbid material, as in rheumatism and gout, 
or from alterations in the supply of blood, through disturbance of the 
vasomotor or trophic-nerve function, cannot be definitely determined 
without further investigation. Many years since, Dr. J. K. Mitchell, of 
Philadelphia, claimed that the primary seat of morbid action in articular 
vheumatism, and other affections of the joints, was in the spinal cord. 
And several of the eminent neurologists of the present time confidently 
claim that arthritis deformans, as well as progressive muscular atrophy, is 
the result of disease in what they term the trophic nerve tract or center in 
the lateral columns of the spinal cord. 

IVeatment. — Whatever may be the theories we adopt in regard to the 
essential pathology of the disease under consideration, it is certain that 
the remedies which have been found most efficacious in the treatment of 
rheumatism and gout, have no influence in controlling its progress. The 
cases that have come under my own observation, have been most bene- 
fited by much rest in a horizontal position; the application, for ten or fif- 
teen minutes each day, of gentle currents of electricity, accompanied b r 
light friction over the diseased articulations and the muscles connected 
with them; the use of a fair variety of plain nutritious food, allowing tea 
and coffee only moderately, and entirely prohibiting alcoholic drinks both 
fermented and distilled, and tobacco; and the administration of a combi- 
nation of iodide of calcium, oxide of calcium, and stramonium, as in the 
following formula: 

3 Syrupi Calcii Iodidi 
Syrupi Calcii Oxydi 
Tincturae Stramonii 

Mix. Shake the vial, and give to an adult four cubic centimeters (fl 3i) 
each morning, noon, tea-time, and bed-time, in a tablespoonful of water. 
Mv observations have led me to think that if the disease should be cor- 
rectly diagnosticated in its early stage, and the plan of treatment I have 
suggested, adopted and faithfully executed for two or three months, a 



130.0 c. c. 


Sit 


60.0 " 


1" 


15.0 " 


|ss 



312 ARTHRITIS DEFORMANS. 

large proportion of the parents would recover. Unfortunately, how- 
ever, a large proportion of the cases are either neglected or treated as 
chronic rheumatism, until the structural changes have become too extensive 
to admit of repair or recovery. 

I have now completed the consideration of all those diseases which I 
had classed under the head of constitutional affections, so far as they come 
under the care of the physician, and will be ready at the next lecture hour, 
to enter upon the consideration of the great class of local, as distinguish- 
ed from acute and chronic general diseases. 



LOCAL DISEASES. 

LECTURE XXXIII. 

General Remarks— Inflammation— Its Nature, Varieties, Anatomical Changes or Results, and the 
Principles involved in its Treatment. 

GENTLEMEN : Having in the preceding lecture completed the con- 
sideration of the first great class of human maladies, embracing the 
acute and chronic general diseases, I now invite your attention to the sec- 
and class, which embraces all the remaining forms of disease under the 
name of local affections. The definition of the words general and local as 
applied to the designation of different forms of disease and the distinctive 
features of each class thus designated, were sufficiently considered in the 
sixth lecture of the present course.* In the same lecture, 1 grouped all 
the local affections into four divisions or sub-classes, calling them respect- 
ively inflammations, fluxes, neuroses, and miscellaneous or un classifiable 
cases. I shall now proceed to consider each of these sub-classes in the 
order in which they were named. The diseases included in the first sub- 
class, called phlegmasia, or local inflammations, are among the most fre- 
quent and important affections that come under the care of the physician. 
The subject of inflammation, like that of fever, has occupied the attention 
of the profession from the earliest periods of medical history; and upon 
these two forms of morbid action have been based all the so-called, great 
systems of medical philosophy of past generations. Until a recent period 
of time all attempts to define inflammation, consisted in a simple enumera- 
tion of the more prominent symptoms presented during the active stage 
of the disease, name y heat, redness, swelling, and pain. It is true that 
when a part or a structure is hot, redder than natural, swollen, and pain- 
ful, it is inflamed. But these several phenomena do not constitute the 
disease. They are simply results or symptoms by which the presence of 
the disease is made known. And there is not one of them that may not 
be absent in some particular case. 

Essential pathology. — If we apply the same analytical method to the 
study of the morbid condition called inflammation, that we adopted in re- 
lation to the essential pathology of fevers, we will find it to involve four 
elements or factors, two of which are essential and uniform and the other 
two variable. The four elements that constitute factors in every inflam- 
matory process, are, the properties of the tissue involved, which I have 
sailed susceptibility and vital affinity and the quantity and quality of the 
blood. The susceptibility or irritability is always exalted and the quan- 
tity of blood increased in every case of inflammation. If the susceptibil- 
ity of the structure is exalted without any accumulation of blood it con- 
stitutes simple irritation. When there is accumulation of blood in the 
vessels of the part, without any increase or exaltation of the susceptibility 

* See Lecture VI, pp. 48-52 of this volume. 

(313) 



Q 



14 INFLAMMATION. 



of the texture, it constitutes simple congestion. When the two co-exist 
in the same structure they constitute the first and essential step in the 
inflammatory process. I call them the constant elements, because they 
are not only always present, but always altered from their natural condi- 
tion in the same direction, though not uniformly in the same degree. The 
vital affinity inherent in all living matter and the quality of the blood, 
are factors present also in every case: but the first may be increased above 
or diminished below its natural standard, or it may be perverted in a di- 
rection differing from either simple increase or diminution of activity, 
while the second may have its plastic elements increased, (hyperplastic) 
diminished, (aplastic) or it may contain foreign constituents, either gener- 
ated in the system or imbibed from without, rendering it toxaemic. There- 
fore I call the vital affinity or property that regulates the movement of 
organic atoms, and the quality of the blood, variable elements of the in- 
flammatory process. 

And a further study will show, that it is the variations in these elements 
or factors, which cause the diversities in symptoms, progress, and results, 
so constantly met with in different cases of inflammation. When th^ 
properties of a structure have been disturbed and blood has accumulated 
in its vessels, constituting the first step in the morbid process called in- 
flammation, these conditions never remain stationary. If the morbid ex- 
citability and the fullness of blood can be at once relieved, the morbid 
process is arrested and the structure restored to its natural or healthy 
condition. In other words the inflammatory process is rendered abortive 
or is cut short in its incipiency. If such a result is not obtained, further 
changes take place which have been carefully studied with the aid of the 
microscope, both in the living tissues and after their death. Under the 
microscope, both the blood and the vessels which contain it are seen rap- 
idly undergoing important histological changes. 

At first the arteries dilate, then the veins, and to a less degree the capil- 
laries. Coincidently the flow of the blood-current is increased, but after 
a somewhat variable time it becomes slower than normal, and in some 
coses even stasis takes place in the capillaries. As it slackens its speed the 
white corpuscles begin to cling and gather along the walls of the veins 
and capillaries, the red blood still flowiig through the center. The white 
corpuscles then begin to migrate. By their amoeboid movements, or the 
increased affinity of the tissue, they push through the intercellular cement 
of the lining endothelium. Outside the vessel they become actively 
amoeboid and change their position through the surrounding tissue. At 
the same time, as a rule, a few, though exceptionally very many, red 
corpuscles also pass from the vessels. The fluid-portion of the blood also 
filters out. These changes constitute the process of exudation. The 
exudate, thus formed, resembles blood plasma, but contains somewhat less 
albumen. The migrated white blood corpuscles are undistinguishable 
from pus cells. Whether they are the sole origin of these cells or whether 
all tissue-cells proliferate and produce the pus cell, is not as yet definitely 
settled by histologists. 

The subsequent steps in the inflammatory process, and the changes in- 
volved in it, will depend entirely upon certain other coincident con- 
ditions. 

If there is an accumulation of healthy, plastic blood, an increased sus- 
ceptibility, and free play of vital affinity, as occurs in the ordinary sthenic 
or active form of inflammation, a plastic exudation is produced. The 
liquor sanguinis, which permeates the tissue, is of such quality, that in- 
fluenced by active vital affinity, it speedily undergoes solidification and 



PATHOLOGY. 



315 



more or less complete organization. As the interstitial spaces are filled 
with this solidified and organized exudate, two things are caused: an in- 
crease of bulk or swelling, and an increase of density or hardening of the 
tissue. Of course, the increase of blood causes an increase of redness; 
and the active play of vital affinity, the rapid exudation and its organiza- 
tion, develops a rise in temperature; the coincident irritation and the 
pressure of th ? exudate cause pain; and thus by successive steps you 
have rapidly developed all the symptoms of phlegmonous or active sthenic 
inflammation, symptoms which are crystalized in the classic words: tumor, 
rubor, calor, dolor. 

But there are other conditions which may modify this result. Suppose, 
instead of the coincidence of active, vital affinity and a healthy plastic 
condition of the accumulated blood, the vital affinity is lowered and the 
blood aplastic: What will be the result? Exudation will take place, and, 
p rhap-, more rapidly than in the other case, as the walls of the capillaries 
and arterioles, uninfluenced or but slightly influenced by vital affinity, 
readily relax, become distended, and yield to the pressure of the accumu- 
lated blood. The liquor sanguinis, which permeates the surrounding tis- 
sue, owing to its aplastic condition and general lack of vital force, remains 
unorganized, or organizes very slowly. The tumefaction, which takes 
place, is not, therefore, accompanied by induration, but the tissue, though 
swelled and red, is only moderately increased in density, and ultimately 
tends to soften and disintegrate, or undergo diffuse suppuration. Good 
examples of this variety are seen in the local asthenic inflammations that 
accompany typhoid and other low grades of general fever. 

A third condition of the blood that may cause important modifications 
of the inflammatory process, arises from the presence in it of some one or 
more foreign substances having properties which are capable of either 
interfering with the ordinary molecular movements and combinations, or 
of altering the vasomotor influence over the action of the vessels of the 
part in a way different from simple increase or diminution. To this class 
of agents belong all the specific contagiums and infections. Their presence 
in the blood of a part excites or exalts the susceptibility, and perverts or 
changes from its natural direction the affinity that controls the movements 
of organic atoms, by which new and specific combinations are formed. 
The inflammations accompanying the eruptive fevers, erysipelas, gout, 
etc., are familiar examples of this variety. From this elementary or 
analytical study, you will see that all cases of inflammation may be in- 
cluded under three heads, which, for want of better terms, I call sthenic, 
asthenic, and specific. 

The elements or factors involved in each, and their differences, will be 
seen by the following table which I place on the blackboard: 



VARIETIES OF 
INFLAMMATION. 



Sthenic. 



Asthenic 



Specific. 



f Susceptibility of structure exalted, 
j Quantity of blood increased, 
j Vital affinity increased. 
I Quality of blood plastic. 



I 



Susceptibility of structure exalted. 
Quantity of blood increased. 
Vital affinity diminished. 
[_ Quality of blood aplastic. 

f Susceptibility of structure exalted. 

j Quantity of blood increased. 

j Vital affinity perverted. 

^ Quality of blood toxeemic or poisoned. 



316 INFLAMMATION. 

You readily perceive that the differences between the sthenic and as- 
thenic depend upon the variations in the vital affinity of the texture an i 
the natural plastic elements of the blood; while the peculiarities of the 
specific inflammations are owing to the presence in the blood of a foreign 
toxaemic or poisonous agent. The two first admit of cases varying much 
in the degree of alteration in the elements involved until those called 
plastic or sthenic, and the aplastic or asthenic, meet so nearly on the di- 
viding line that the practitioner may properly hesitate in deciding un- 
der which head a given case before him should be placed. 

Results or Terminations of Inflammation. — The inflammatory process, 
when it progresses beyond the first stage of its existence, may terminate 
by resolution, by formation of new tissue, by suppuration, and by gan- 
grene. As I have already explained, the first stage of inflammation con- 
sists of simple morbid excitability of the structure and accumulati n of 
blood in its vessels; and the second embraces the period during which 
more or less of the constituents of the blood are passing through the walls 
of the capillaries into the interstitial spaces, and is often called the stage 
of exudation. The first is usually very brief, occupying from six to twen- 
ty-four hours. The second more generally continues from two to five 
days; and is followed by the third or stage of decline, during which the 
results of the inflammatory process are developed, either in resolution, 
the permanent organization of new or false tissue, the formation of pus 
(suppuration), or the death of the part (gangrene). These diverse results 
which are liable to be developed during the third stage, depend entirely 
upon the quantity and quality of the exudation material and the condi- 
tion of the vital affinitv of the structure involved. If the amount of the 
exudate, whether plastic or aplastic, is moderate, and the affinity or prop- 
erty regulating the movement and combination of organic atoms or mole- 
cules not much below the natural standard of activity, it generally begins 
to undergo disintegration and removal by re-absorption as soon as the ex- 
udative process is arrested, and in a few days the whole is removed, leav- 
ing the original structure in its natural condition. This constitutes the 
termination by resolution. 

If the amount of the exudate is moderate and decidedly plastic with an 
active state of vital affinity, as in acute rheumatic and other sthenic 
grades of inflammation, it not only undergoes rapid solidification, but its 
molecules are arranged into cells, nuclei, and granules, which become more 
or less assimilated in form and function to the normal tissue in which the 
exudation occurs. The structur : thus becomes hypertrophied and often 
permanently much embarrassed in the performance of its function. The 
thickened and indurated valves following endocarditis; the sclerosis of 
the connective tissue of the lungs, resulting in some cases from pneumo- 
nia; and parallel changes in the parenchyma of the liver, spleen and oth- 
er organs, resulting from attacks of active inflammation, are all familiar 
examples of inflammation terminating in the formation of new tissue. 
When the serous membranes are the seat of the same grade of inflamma- 
tion, the blood plasma, containing the plastic materials, exudes upon the 
surface of the membrane, the endothelial cells of which are pressed apart 
or detached, and a deposit of fibrin, holding in its meshes white cor- 
puscles and granular matter, accumulates. At the same time the connect- 
ive tissue cells of the surface enlarge and become more or less imbedded 
in the layer of exudate. These cell structures multiply, a new basement 
substance is formed, in which new blood vessels appear, while the fibrin 
and serous fluid are removed by absorption, and a layer of complete con- 
nective tissue is left in the form of a false or new mem rane closely iden- 
tified with the surface of the natural one. 



RESULTS OF INFLAMMATION. 317 

Or if two inflamed surfaces arc in contact, the layer of new connective 
tissue becomes a permanent bond of union between them, as you see 
often in the pleuritic, pericardial and other membranous adhesions follow- 
ing- attacks cf the more sthenic grades of inflammation. When th3 grade 
of inflammation is asthenic, the exudation takes place, either into the 
parenchyma of organs or upon the surface of membranes, in the same 
manner as just described, and the exudate generally partially solidifies, 
presenting many of the characteristics of new tissue or membrane, as you 
may see in the exudations of diphtheria. But its organization is never 
complete, and it soon disintegrates and disappears, often accompanied by 
softening or ulceration of the inflamed structure. 

Suppuration or the formation of pus, may result from any grade or 
variety of inflammation, and will occur whenever the exudation in any 
given case is sufficiently copious to crowd either the white corpuscles of 
the blood or the proliferating connective tissue cells beyond the influence 
of the properties inherent in the Hying organized structure. In the most 
active sthenic grade of inflammation where the blood is plastic, and both 
properties of structure exalted, giving to the exudate a strong tend- 
ency to organization, you can readily conceive that in the central parts 
of the inflamed portion of structure where many of the capillaries are 
completely blocked up by the accumulated corpuscular elements, the 
amount of exudation might so distend some of the interstitial spaces as to 
leave more or less of the leucocytes and other cell elements beyond the 
vitalizing influence of the living fibres bounding such interstitial spaces. 
The ceils and corpuscles thus placed, immediately commence undergoing 
degeneration, and generally assume the form of pus corpuscles, and mark 
the beginning of the suppurative process. 

While these points of suppuration are being formed in the more in- 
tensely engorged central parts of the inflamed structure, in the less en- 
gorged parts toward the circumference, the whole amount of the exudate 
retains its integrity, simply causing increased bulk, density, redness and 
heat. The central points of suppuration soon unite, forming an abscess, 
bounded by the denser part of the tissue, thus constituting the typical 
phlegmonous nbscess of the older writers, whose plastic lymph meant the 
same thing as the exudate or plasma, with its leucocytes, proliferating 
cells, etc., of the histologists of our time. 

In the asthenic grades of inflammation, with the properties of the struct- 
ure impaired, and the exudative material diminished in its plasticity, if 
the amount of the latter proves sufficient to so far distend the interstitial 
spaces as to crowd the white corpuscles and cell elements beyond the 
vitalizing influence of the tissue properties, they suffer purulent degenera- 
tion still more rapidly than in the cases just described. And as no part 
of the exudate becomes more than partially organized, the points of puru- 
lent degeneration are not limited or circumscribed by dense tissue, as in 
the sthenic or phlegmonous variety, but multiply rapidly throughout 
the whole of the inflamed structure, constituting what is called diffuse 
suppuration, and often involving extensive softening or destruction of the 
part. 

In the specific inflammations, or those caused by the presence of some 
special poison in the blood, if suppuration takes place, it will be either 
circumscribed or diffuse according to the nature of the poison, and the 
previous constitutional condition of the patient. Some of the specific 
poisons excite inflammations that are always accompanied by suppuration. 
Such is the poison of variola and vaccinia, each cutaneous pustule they 
produce being a miniature phlegmon. 



318 INFLAMMATION. 

The inflammations caused by others are accompanied by suppuration 
only in cases of unusual severity, and then the suppurative process is gen- 
erally diffuse. Such are the poisons causing scarlatina, measles, diph- 
theria, and erysipelas; while the inflammations of gout and rheumatism 
seldom present any degree of purulent formation. 

Gangrene. — Death of more or less of the inflamed part, or gangrene, 
was mentioned as a fourth result of the inflammatory process. 

In the ordinary sthenic and asthenic grades of inflammation, gangrene 
or loss of vitality in the structure, is caused by simply increasing the same 
conditions that give rise to suppuration. The exudation is not only copi- 
ous enough tooverdistend some of the insterstitial spaces, and produce 
stasis in some of the capillaries, but to completely arrest the circulation of 
blood in a portion of the inflamed structure. Such complete arrest of cir- 
culation is necessarily followed by the cessation of all molecular change, 
and consequently the cessation of life in the part. It is probable that in 
some of the inflammations caused by specific poisons of the more virulent 
class, gangrene may be owing, in part at least, to the direct action of the 
poison on the properties of the tissue, diminishing the susceptibility and 
so far diverting the affinity as to arrest all nutritive or molecular changes. 
In speaking thus far of the results of inflammation I have omitted to men- 
tion that when membranes are the seat of the disease, much of the 
exudate is from the watery element of the blood, and consists chiefly of 
water holding in solution a small proportion of albumen and saline con- 
stituents, and sometimes the red corpuscles of the blood. When the mu- 
cous membranes are inflamed, their surfaces having free outlets, the exu- 
date passes off in the form of evacuations, composed of either water, mucus, 
blood, or pus, and not unfrequently of all these mixed in different proportions 
at different stages in the progress of the case. When the serous membranes 
are affected, the liquid part of the exudate is more largely composed of 
water, with only a small proportion of albumen, and as these membranes 
are shut sacs, the fluid accumulates, distending the sac, or pressing inju- 
riously upon the contained viscera, as the lungs, heart or brain. These 
cases are more frequently called effusions than exudations, and the accumu- 
lations are called dropsies. Inflammation in any of the membranes may 
also t rminate in suppuration by the same process that I have already de- 
scribed, only the pus will appear principally upon the surface of the mem- 
brane involved, and in the shut sacs accumulate like the serous fluids and 
is often mixid with them. From the analytical review I have now given, 
you have seen that the morbid process called inflammation, like that of fever, 
always involves at its beginning certain elements or factors, some of 
which are constant, and others subject to such variations as to cause ma- 
terial alterations in the progress and results of different cases. There is a 
oneness or unity in all inflammations, inasmuch as they all involve the 
same elements or factors at the beginning, but a wide diversity in the prog- 
ress and results of different cases, on account of the variable condition of 
two of the primary factors, as well as the diverse character of the remote 
and exciting causes. You have seen also that all the varieties of inflam- 
mation when uninterfered with, pass through the same stages, namely, that 
of tissue irritability and vascular engorgement, that of exudation, and that 
of decline. The first, the same in kind in all cases, varying only in the 
degree of intensity. The second varying much both in regard to the quan- 
tity and quality of the exudate. And the third still more variant both in 
regard to the character of the changes that accompany it, and the ultimate 
results. I thus restate, in explicit language, the points of unity and the 
lines of divergence seen in studying the pathology of all varieties of in 



TREATMENT. 319 

flimmation, and the distinct stages which mark their progress, because I 
deem a clear recognition of them of the greatest practical importance at 
the bedside of the sick. In the first stage, I recognize the co-equal impor- 
tance of the quantity and quality of the blood, and of the disturbed prop- 
erties of the tissues by which the molecular changes and tonicity of the 
vessels are regulated; in the second, of the combined influence of blood 
pressure on ovcrdistended and partially obstructed vessels and capillaries, 
and of the altered affinity or attraction between the tissue elements and 
those of the blood, in determining the amount and rapidity of the exuda- 
tion; and in the third, of the mutual influence of the tissue properties, and 
of he amount and quality of exudative material, in determining whether 
the result will be resolution, new tissue evolution, suppuration or gan- 
grene. By so do'ngl hope to guard you against the extreme views of 
Hunter and his followers, who place all the essential pathological phenom- 
ena of inflammation in the blood and the blood vessels; and till more against 
the partial and narrow views of Virchow, Hughes, Bennett, and their fol- 
lowers, who would have us regard the inflammatory process as essentially 
one of simple cell irritation and proliferation. I would not have you 
neglect or undervalue the important additions made to our knowledge 
concerning the histological changes in the development and progress of 
inflammation by such men as Virchow, Waller, Recklinghausen, Conheim, 
etc.; but I would have you fully aware of that trait in the human mind 
which disposes it to magnify the importance, and unduly extend the ap- 
plication of each new discovery it makes, and as physicians, whose pri- 
mary object is the prevention and alleviation of human suffering, I would 
have you careful to avoid conclusions based on only a part of the facts be- 
longing to any question or case, and to bring every man's theories to the 
test of impartial clinical as well as dead house observations. 

As you have already noticed, inflammation is not a simple uniform morbid 
process; consequently when you have decided that a patient is laboring un- 
der an attack of inflammation in some organ or structure, you have not 
completed your diagnosis. A more delicate and equally important task 
still remains; namely, to judge accurately of the special character of the 
inflammation by appreciating clearly the quality of the patient's blood, the 
condition of the elementary properties of his tissues, and the nature of the 
causes which have been efficient in determining the attack. 

Principles of Treatment. — From the views I have presented concerning 
the nature and tendencies of the different grades of inflammation, you see 
clearly the futility of all the great controversies that have been had (and 
they are many) concerning the treatment of inflammation on the theory 
that it is a uniform morbid process. To claim that all inflammations must 
be treated antiphlogistically, by depletion, sedatives, evacuants and low 
diet; or by stimulants, tonics, and nourishment; or by simple rest, mild 
diet, and patience; is equally unphilosophical and almost equally injurious 
to a large part of the patients. Either of these methods would succeed in 
some cases and signally fail in others. And yet there is too much of the 
old idea still lingering in the minds of the profession, that inflammation is 
a specific and uniform morbid process, and all you have to do is to deter- 
mine its existence and location and then treat it according to the general 
routine. There are, however, certain leading objects to be accomplished 
in the treatment of all inflammations whether sthenic, asthenic, or specific. 
These are founded on the pathological conditions existing in each stage 
of the inflammatory process, and may be placed in tabular form on the 
blackboard as follows: 



320 



INFLAMMATION. 



INDICATIONS 
FOR TREATMENT 

IN ALL 
INFLAMMATIONS. 



! To dimin'sh the susceptibility or irrita- 
bility of the structure, and correct the vital 
1st Stage. ■{ affinity. 

b. To relieve the vascular fullness or ac- 
cumulation of blood. 

a. To limit the amount of exudation, and 
lessen the general fever. 

b. To prevent the injurious accumulation of 
2d Stage. effete material from the interference with 

excretory functions, by promoting elimina- 
L tions. 

' a. To promote the removal of the exudate 
by resolution. 

b. To sustain the functions of nutrition and 
3d Stage. ■{ excretion. 

c. To promote the repair of structures in- 
jured, either by suppuration, gangrene, 
sclerosis, or atrophy. 

While the indications to be fulfilled or objects to be accomplished in 
each stage of the inflammatory process are the same as just stated in all 
cases, the means appropriate for fulfilling them will vary with each varia- 
tion in the grade of the disease; and to some extent also, with the differ- 
ences in the structure and function of the parts involved. For example: 
in the first stage of the sthenic grade of the disease, the chief agents for 
correcting the properties of the inflamed structure are anodynes and ner- 
vous sedatives, and for relieving the vascular fullness or accumulation of 
blood, direct depletion and vascular sedatives. In the same stage of the 
asthenic grade, direct depletion must be omitted and the nervous and vas- 
cular sedatives must give place to tonics, especially of the vasomotor 
class and such as sustain the vital affinity or molecular action in the struct- 
ures involved. And in the corresponding stage of the specific grades, 
the leading remedies are such as will suspend the further action of the 
specific cause by neutralizing (antiseptics) or expelling (eliminants) such 
cause, aided by anodynes, and either sedatives or tonics, according to the 
condition of the vascular and nervous functions in each case. The rela- 
tive importance of the two leading indications to be fulfilled in the treat- 
ment of the first stage of inflammation, will depend much upon the ana- 
tomical character and function of the part affected. If the structure is 
dense and but little vascular, like the cartilages, ligaments, periosteum, 
and some of the serous membranes, the amount of tumefaction or exuda- 
tion will seldom be sufficient to suspend any function essential to life. 
Consequently in all such cases you can properly depend much more upon 
those measures designed to reduce the morbid excitement or irritation of 
the structure, than upon those aimed at the lessening of the amount of blood 
in the vessels of the part. If the structure involved be highly vascular and 
the connective tissue yielding, as in the parenchyma of the lungs, spleen, 
liver, brain, etc., and the function of the part such that its interruption, 
temporarily, may directly or indirectly endanger life, then early relief to 
the vascular fullness is of paramount importance as the chief means for 
limiting the amount of exudation or effusion. In such cases the means for 
lessening the accumulation of blood in the part must take the precedence 
of all others, The complete fulfillment of either of the objects I have 
named in the first stage will render the disease abortive, and the same re- 
sult will be reached still more certainly, by judiciously directing the 
means for accomplishing both at the same time. 



INFLAMMATION OF THE BRAIN. 3^1 

The accomplishment of the first object named as desirable in the second 
stage of inflammation, will be best effected by continuing the use of the 

same remedial agents that have been mentioned as applicable in the first 
st aire. 

The means for accomplishing* the object marked b, in the second stage, 
must depend much upon the particular excretory functions interfered 
with in any given case. Diaphoretics, diuretics, mild laxatives and alter- 
atives or excitors of glandular secretions generally, will all be found ap 
plicable in different cases, according to the seat of the disease. 

The three indications named as belonging to the third stage of the in- 
flammatory process, will be best fulfilled by a moderate continuance of 
the remedies required in the second stage, aided by close attention to 
nourishment, good air, and such tonics as promote assimilation and nu- 
trition. 

So far as the limits of a single hour will permit, I have given you an 
analytical view of the essential pathology, modes of progress, and results 
of inflammation ; and the general principles that should govern its treat- 
ment. Your careful attention to this general consideration of the sub- 
ject will greatly facilitate your study of inflammations of the individual 
organs or structures, and enable me to economize time by avoiding repe- 
titions. 



LECTURE XXXIV. 

Inflammation of the Brain and Spinal Cord and their Meninges— The structures involved and 
their Anatomical Characteristics— Subdivisions and Names Applied to Infiammatiou of each Part 
—Their Clinical History or Symptoms, and Diagnosis. 

GENTLEMEN : By the brain, spinal cord and their meninges, I mean 
the masses of nerve matter called cerebrum, cerebellum, medulla 
oblongata, and spinal cord, with their three investing membranes, called 
dura mater, arachnoid, and pia mater. The nerve masses are soft, 
inelastic, minutely vascular, and so delicate in structural arrangement as 
to be easily injured, were they not protected by complete inclosure with- 
in the bones of the cranium and spinal column. The outer membrane or 
dura mater is thick and dense, with little vascularity. The second, or 
arachnoid, is very thin and delicate, only moderately vascular, and like 
the outer one, spread over the convolutions and surface of the brain and 
cord, with only slight attachments to them. The inner membrane, or pia 
mater, is also thin and delicate in structure, but very vascular and by its 
vessels closely connected with the surface of the brain, dipping deeply 
down between the convolutions, and extending into the lateral ventricles. 
I remind you of these simple anatomical facts because they have some 
relation to the changes that may be expected to take place during the 
progress of an active inflammation, as I explained in the preceding 
lecture. Inflammation may attack either of the membranes separately, or 
either of the anatomical divisions of the nerve matter ; or it may invade 
the whole at once. Clinical observations, however, have shown that the 
dura mater is rarely attacked, except as a secondary or remote effect of 
syphilis and alcoholism, or as a complication of inflammations of the middle 
ear, or as a chronic affection of old age. Neither is the arachnoid often 
21 



322 PACHYMENINGITIS. 

attacked, except in children of scrofulous or tuberculous tendencies, or as 
a result of the actual deposit of more or less of the gray, miliary tubercle. 
The pia mater is generally the primary seat of ordinary attacks of acute 
and subacute inflammation, both in children and adults. From its close 
vascular connection with the surface of the brain, the latter almost uni- 
formly becomes also immediately involved in the inflammatory process. 
Practically, therefore, inflammation of the pia mater and convolutions or 
surface of the nerve masses is one disease. Inflammation of all grades 
may occur in the interior of either division of the brain or in the cord, 
without involving the surface, although such cases are not of frequent oc- 
currence. When inflammation attacks the brain and its investing mem- 
branes generally, it is properly called encephalitis. When it attacks the 
membranes alone it is called meningitis, or the brain structure alone, it is 
cerebritis. As I have already explained, however, meningitis as it affects 
the pia mater, can rot be clinically separated from inflammation of the 
convolutions of the brain. Consequently in the further discussion of this 
subject I shall use the word pachymeningitis to indicate inflammation of 
the dura mater; meningitis, to indicate inflammation of the arachnoid and 
pia mater and surface of the brain together, and cerebritis to indicate the 
disease when it involves the interior of the brain alone. For convenience 
of description, I shall adopt the following nomenclature: pachymeningitis, 
meningitis, tuberculous meningitis, cerebritis, cerebral sclerosis, cerebro- 
spinal meningitis, sporadic and epidemic; spinal meningitis, and myelitis. 

Pachymeningitis. — As I have already stated, the dura mater is seldom 
the seat of simple acute inflammation as a primary affection, but is often 
involved as the result of blows, mechanical injuries, and surgical opera- 
tions, affecting the bones of the cranium. Such cases, however belong to 
ithe department of surgery, and are fully considered in surgical works, and 
in the courses of instruction in that department of this and other medical 
■co'leges. 

Chronic inflammation is more frequently observed in connection with 
certain constitutional impairments or diatheses, and is often difficult ot diag- 
nosis, and still more difficult to remove by remedial management. As the 
dura mater is composed of two layers, the outer one attached to the inner sur- 
face of the cranial bones, like ordinary periosteum, and the inner one pre- 
senting a smooth, free surface, covered with epithelium, most observers 
have described the existence of inflammation in the first as pachymenin- 
gitis externa ; and in the second as pachymeningitis interna. If 
we omit the traumatic * cases as belonging to surgery, nearly all 
of those classed as belonging to the outer layer have been found in 
connection with the cerebral atrophy of old age. Many of these had 
presented no symptoms during the life of the patient, while others 
had been characterized by long continued, dull pain in the head, a creep- 
ing or crawling sensation in the pericranium, and sometimes in different 
parts of the cutaneous surface of the body or extremities; general im- 
pairment of strength and steadiness in the voluntary muscular system; in 
some cases morbid wakefulness, and in others almost constant drowsiness; 
and very generally impairment of the special senses, and of memory. 

The morbid anatomy of these cases consists essentially in sclerosis, or 
thickening of the fibrous structure of the dura mater, with closer adhesions 
to the bones of the cranium than natural, and in some cases, the deposit 
of granules or nodules of bony matter, called osteophytes, analogous to the 
deposits sometimes found in i ases of old periostitis of the long bones. It 
is proper to state that in nearly all these cases called external chronic 
pachymeningitis, the post mortems show, in addition to the changes 



SYMPTOMS. 32 



in the dura mater, more or less of the general cerebral atrophy 
peculiar to old age. And it is hardly proper to regard those cases which 
have presented no symptoms during life, and after death show only slight 
increased adhesions of the dura mater to the bone, with here and there an 
osseous granule, as in any degree inflammatory. They clearly belong 
rather to the series of changes dependent on the impairments ai)d per- 
versions of nutrition consequent on old age, instead of on any degree of 
inflammatory action. 

Under the head of pachymeningitis interna, writers have included a 
variety of cases which have occurred chiefly in persons habitually addicted 
to the use of alcoholic drinks, or affected with the general paralysis of the 
insane, or with constitutional syphilis, or undergoing the degenerations of 
old nge. Sometimes the changes in the dura mater have been traced to 
the influence of blows, or mechanical injuries of the head. As might 
be expected from the statement just made, far the larger proportion of 
cases occur in persons past the middle period of life, and much more fre- 
quently in males than in females. 

The symptoms and clinical history of the cases reported by different 
observers vary so much that it is difficult to specify such features as are 
reliably diagnostic of the disease. I think this arises mainly from the 
fact that writers have included under this head many cases of haemorrhage 
from the inner surface of the dura mater caused by changes thac are not 
really of an inflammatory character, and many other cases which were 
associated with such coincident affections of the brain as to render it im- 
practicable to separate or recognize the symptoms of the meningeal disease. 
Of this latter character were cases II and IV", as reported by Dr. C. L. 
Dana, in the Journal of Mental and Nervous Diseases, for January, 1882. 
Of the former class I regard some of the cases reported by Huguenin, 
whose field of observation was largely among those affected with the 
general paralysis of the insane.* 

My own clinical observations incline me to believe that all cases of an 
inflammatory character in the early stage are characterized by frequent 
pains in the head, accompanied by morbid sensations of heat over the top 
of the head, much increased by exposure to the sun; more or less vertigo, 
or rather a feeling of insecurity in walking or making quick movements; 
various morbid sensations over limited areas of the cutaneous surface, 
both of the trunk and extremities; and disturbed sleep. 

As the disease advances, the headaches are frequently accompanied by 
tinnitus or buzzing in the ears; mental stupor, or somnolence, accompanied 
by partial paralysis, or at least greater impairment of muscular action; 
sometimes muscular twitchings, or temporary periods of rigidity, or even 
epileptiform convulsions. 

After the disease is well established, one of the most characteristic feat- 
ures is the occasional sudden supervention of periods of profound somno- 
lence, lasting from a few hours to one or two days, then passing off, 
leaving the patient weak, but the mind clear, though sometimes a little 
difficult to give expression to the thoughts, or to command ready co-ordi- 
nation of muscular movements. Occasionally it will happen that the 
period of somnolence will be replaced by a paroxysm of incoherent talka- 
tiveness and excitement. Ultimately the mental faculties become more 
constantly impaired, with imperfect control over the sphincters of the 
bladder and rectum, ending in general paralysis and death. Some of the 
cases terminate more abruptly by the sudden supervention of profound 
coma, dilation of the pupils, involuntary discharges, slow and intermitting 

* See Ziemsseix's Cyclopaedia, Vol. xii, p. 385. 



324 PACHYMENINGITIS. 

pulse, cold extremities, and death in from one to thirty-six hours after 
the coma commences. Two well marked cases of this kind have recently 
come under my own observation. During all the earlier part of the dis- 
ease, there will be temporary periods of slight pyrexia, accompanied by 
loss of appetite, general impairment of secretory actions, and more severe 
headaches. 

But most of the time the temperature is not higher than natural, and 
the patient takes food and drink readily. During the paroxysms of som- 
nolence the pupils are generally much dilated, or one is largely dilated 
while the other is contracted, and I recollect one case in which the pupils 
became closely contracted while the patient was in the paroxysm of stupor, 
with the lids closed, but when the lids were separated, and efforts made 
to arouse the patient, they became rapidly and fully dilated. 

Diagnosis. — If the peculiarly variable train of symptoms I have detailed 
are observed in a patient previously long addicted to free use of alcoholic 
drinks, or long subject to insanity or hemiplegia, or presenting indications 
of degeneration from old age, you may safely infer the existence of true 
pachymeningitis interna. It is only by including under this head cases of 
meningeal haemorrhage from cerebral atrophy alone, atheromatous or fatty 
degeneration of the coats of the vessels, and other pathological conditions, 
unaccompanied by any degree of inflammation, that the diagnosis becomes 
difficult and uncertain. 

Special Pathological Changes. — The changes which are regarded as 
specially characteristic of this form of disease are the formation of a deli- 
cate and highly vascular layer of membrane or organized structure on the 
inner surface of limited portions of the dura mater, chiefly along either 
side of the longitudinal sinus and falx cerebri, and sometimes extending 
in patches over most of the parietal regions; and more or less indications 
of haemorrhages, in connection with the membranous formation. The 
membranous patches are at first very thin and easily overlooked, often 
appearing like a slightly yellowish stain on the surface of the dura mater. 
Examined under a magnifying power they are found to consist principally 
of blood vessels with extremely thin walls and varicosities, with very little 
fibrous or connective tissue. The larger patches also very generally pre- 
sent evidences of small haemorrhages from the vessels, the serum of which 
had been absorbed leaving the stain of coloring matter and some shreds of 
fibrin adherent to the membrane. It is these repeated small hemorrhages 
that cau e the paroxysms of temporary somnolence, contraction of the 
pupils, and partial paralysis, which mark the progress of these cases. 

In some instances the hemorrhages are more copious causing either 
hemiplegia or apoplexy which may prove speedily fatal, or from which 
the patient may slowly make a partial recovery. The new membranous 
patches together with the adhering debris of the blood clots are called 
ho&matomoe and many of them are sufficiently thick to press injuriously 
upon the convolutions of the brain, and sometimes to present slight ad- 
hesions to the arachnoid and pia mater. 

As a large proportion of the cases of pachymeningitis occur in patients 
already undergoing more or less cerebral atrophy, it is highly probable 
that the patches on the surface of the dura mater consisting primarily of 
delicate- vessels with thin walls and many varicosities, result directly from 
the diminished pressure on the surface of the membrane, for as the mass of 
the brain shrinks, the bones to which the dura mater adheres cannot follow 
the shrinkage. Consequently, there will be less pressure on the free surface, 
and a corresponding tendency to distension of, and exudation and even hem- 
orrhage from the capillaries and smaller vessels, without the intervention of 



TREATMENT. 325 

any true inflammatory process. In such cases the views of Huguenin, 
who denies this inflammatory nature, are more nearly correct than those 
of Yirchow and his followers, who regard all the patches as originating in 
inflammatory exudations. 

Prognosis. — The form of disease under consideration, occurring usually 
in connection with impaired constitutional conditions that are often per- 
manent, lias no natural tendency to recovery and is not generally cured 
by remedial agents. Neither is there any natural limit to the duration of 
the disease. It may terminate early and suddenly from copious hemor- 
rhage and fatal compression of the brain, or it may continue for several 
years. 

Treatment. — The treatment must consist in removing as far as possible 
all causes of mental and cerebral excitement, in improving whatever con- 
stitutional impairment may exist in each case, and in the use of such rem- 
edies as are supposed to increase the tone and contraction of the menin- 
geal vessels, in the hope of lessening the size and fullness of the vessels 
composing the membranous patches or hsematomse, and thereby retard 
their growth and lessen the danger of hemorrhage. Perhaps no remedies 
do this more reliably than ergot ine aided by digitalis when the cardiac 
action is quick and weak, and by strychnine and iron when it is slow and 
irregular with anaemia or impoverishment of the blood. The proper ad- 
justment of diet and exercise to the general constitutional condition of the 
patient; the entire prohibition of the use of any kind of alcoholic drinks, 
tobacco, and all other agents that exert an anaesthetic or paralyzing influence 
on the vasomotor nerve functions; and the judicious use of such reme- 
dies as I have just mentioned will constitute the best treatment both for 
retarding or arresting the progress of the meningeal disease, and prevent- 
ing the frequent hemorrhages to which these cases are liable. When 
such hemorrhages do occur, it may be necessary to add, temporarily, the 
use of mild evacuants, and moderate doses of iodide of potassium, to 
hasten the re-absorption of the serous part of the effused blood and there- 
by lessen the pressure upon the brain. In such cases as have a manifest 
syphilitic constitutional taint, the more persistent use of the iodides aided 
by the occasional use of mercurial alteratives will be beneficial. 

Meningitis. — As I have already stated, by meningitis I mean inflamma- 
tion of the pia mater and convolutions of the brain. The grade of inflam- 
mation may be either acute, subacute, or chronic. It may involve the 
whole extent of the membrane and surface of both hemispheres, or it mav 
be limited to one hemisphere, or even to a circumscribed part extending 
over only a few convolutions. It occurs much more frequently in children 
under five years of age than in adults. 

Causes. — Among the more important predisposing causes, are, the 
greater vascularity and less maturity of structure in early childhood; the 
greater excitability and less tonicity characteristic of the scrofulous and 
tuberculous diatheses; habitual excess of mental exercise and confinement 
in-doors; protracted mental anxiety with deficient sleep, and the free use 
of rich and highly seasoned food with what are called stimulating drinks. 

The more immediate exciting causes, are, exposure to the extremes of 
heat and cold; sudden and intense mental emotions and passions; intense 
and protracted mental exercises of any kind; the deposit of gray miliary tu- 
bercular granules; and the presence in the blood of irritative material 
whether in the form of retained excretory products derived from the nat- 
ural tissue changes, or of toxemic agents imbibed from without. 

Symptoms, or Clinical History. — Simple acute meningitis usually com- 
mences rather suddenly, though it may be preceded several days by some 



326 



MENINGITIS. 



headache, vertigo, flushed face, with starting and restlessness at night. At 
the actual beginning of the inflammation the pain in the head becomes in- 
tense, often, particularly in children, accompanied by a few minutes of 
paleness of the features and sudden ejection of the contents of the stomach 
by vomiting. This is quickly followed by general febrile action, charac- 
terized by flush of the face, congestion of the vessels of the conjunctiva, 
contraction of the pupils, distracting pain and undue heat in the head, 
fullness and tension of the carotid and temporal arteries, pulse full and 
frequent, respiration hurried, mind excited and generally more or less de- 
lirious, sometimes wildly so, urine scanty and high-colored, and bowels in- 
active. In children under five years of age this stage is in manv cases 
ushered in by one or two general convulsions, followed by the assemblage 
of symptoms just detailed. And when convulsions do not occur in young 
children, the intense pain and delirium are indicated by sudden starting, 
screechings, biting of the fingers, or whatever is put into their mouths, 
pulling of their hair, and reckless tossing from side to side. In all cases 
of acute meningitis the temperature of the head and body rises rapidly, 
and usually ranges during the stage of excitement between 39° and 40.5° 
C. (102° and 105° F.) in the axilla. After a period, varying from twelve 
or eighteen hours to three or four days, the symptoms begin to change. 
The symptoms indicating pain in the head and mental excitement dimin- 
ish, the temperature falls one or two degrees; the pulse is softer and a 
little unsteady, the pupils vacillate, being sometimes contracted and in a 
few minutes dilated, or more frequently one pupil dilates while the other 
remains small; and the patient has brief periods of apparent sleep, and is 
noticed to be much less sensitive to light and noise. 

On the supervention of these symptoms or rather abatement of the pre- 
vious symptoms, the friends and sometimes the attending physician are 
greatly encouraged, thinking the patient better. But in twelve or eighteen 
hours more, it is found that the periods of apparent sleep have deepened 
into stupor; with soft, weak, irregular pulse; unsteady and inefficient res- 
piratory movements; dilated pupils and strabismus or divergence of one or 
both eyes; cool extremities; and difficulty of deglutition. In young children, 
the stage of transition from high excitement to that of stupor and depres- 
sion, is in many of the cases, marked by the occurrence of general convul- 
sions, followed speedily by coma, paralysis, involuntary discharges and death. 
And in cases not marked by convulsions, whether in children or adults, 
the stupor gradually deepens into profound coma; the respirations become 
very slow or interrupted; the pulse small and frequent; the eyelids only 
partially closed; the pupils widely dilated and deglutition suspended; fol- 
lowed by general paralysis and death. There are thus three distinct pe- 
riods or stages in the progress of each case that proceeds to a fatal result. 
The first is the stage of high irritative excitement, lasting, as I have al- 
ready said, from eighteen hours to three or four days. The second is the 
period of transition from high excitement to stupor and depression, and is 
of much clinical importance as marking the commencement of exudation 
and effusion from the previously inflamed and over-distended vessels; and 
usually lasts from twelve to twenty- four hours. The third stage is that in 
which the inflammatory products, consisting of a serous or seropurulent fluid, 
with some fibrinous material, has accumulated in sufficient quantity to com- 
press the brain and impair or overwhelm its functions, and varies in its 
duration from a few hours to five or six days, depending upon the rapidity 
and extent of the exudation. In the milder class of cases, and in such as 
are favorably modified by early and active treatment, the first stage is 
generally longer, but the symptoms of excitement are less severe, and the 



SYMPTOMS. 327 

vascular fullness subsides with so little exudation or effusion that convales- 
cence follows instead of the third, or stage of depression. You are liable 
to meet with a class of cases, chiefly in children under ten years of age, in 
which the symptoms preceding and accompanying the first stage are more 
obscure and much more liable to be misunderstood. In this class of cases, 
the child first begins to look sad or dejected; has a variable or capricious 
appetite; is restless or frequently starts or cries out in his sleep; pulse a 
little accelerated in frequency; temperature from one to two degrees high- 
er than natural, more particularly in the afternoon and evening, but looks 
pale in the morning with but little disposition to exercise, and sometimes 
promptly rejects by vomiting whatever is first taken into the stomach in 
the morning. The bowels are usually costive, but in the summer season 
there is in most of the patients frequent turns of moderate diarrhoea with a 
very variable condition and color of the discharges. After one or two weeks 
of these variable and apparently mild symptoms, during which the child is 
usually dressed and up more or less every day, there comes, in some of the 
cases, suddenly one or more general convulsions, which are followed by 
more fever, more signs of pain in the head, more contraction of the pupils, 
more gastric irritability, a more frequent and somewhat variable pulse, 
and indisposition or inability to assume the upright position for more than 
a few seconds at a time. 

In perhaps a majority of the cases the same increase or exaggeration 
of the symptoms takes place without the occurrence of general convul- 
sions. After continuing with but little variation in the character of the 
symptoms, except a steady increase in the loss of flesh and strength, from 
one to two weeks after confinement to the bed, the patient begins to appear 
more dull and difficult to arouse; one or both pupils are observed to be 
larger than natural and the eye turned from its natural position, and in 
one or two days more all the symptoms I have mentioned as indicating 
the accumulation of inflammatory products sufficient to produce cerebral 
compression, coma, paralysis, and death. Many of this class of cases are 
entirely misunderstood in all the earlier part of their progress, and their 
symptoms attributed to teething, worms, gastro-intestinal irritation, or in- 
fantile remittent fever; their true character not being suspected until 
either convulsions or the symptoms of direct cerebral compression have 
supervened. 

Scrofulous wr Tubercular Meningitis. — The last cases described may be 
regarded as occupying an intermediate relation, or as forming a connect- 
ing link between the ordinary form of acute meningitis and that which 
occurs in connection with a strongly scrofulous diathesis or an actual tu- 
bercular deposit in the membranes and surface of the brain. The latter 
class of cases was recognized and described by the older writers under the 
names of acute and chronic hydrocephalus. This name was suggested by 
the fact that post mortem examinations very uniformly showed a large 
amount of serous fluid on the exterior surface of the pia mater, and often 
extending into the lateral ventricles; and the presence of the small, gray, 
or miliary tubercles in the arachnoid, pia mater, and cerebral convolutions 
was not recognized until a later period. 

The symptoms in many of the cases belonging to this class are at first 
obscure and very variable. They are most apt to be manifested between 
the ages of one and seven years; yet they have been met with at all periods of 
life. In the great majority of cases the earliest symptoms are frequent turns 
of headache, accompanied by slight fever, and sometimes vomiting; restless- 
ness at night, manifested by startings, crying out in sleep, and frightful 
dreams; gradual loss of flesh, with variable appetite and moderate consti- 



o 



28 TUBERCULAR MENINGITIS. 



pation, the latter occasionally interrupted by a day of diarrhoea; and gener- 
ally paleness, with a sad expression of countenance in the morning, fol- 
lowed by more color and cheerfulness in the afternoon, with slight accel- 
eration of pulse, and a rise of one or two degrees in temperature. These 
symptoms are usually noticed more or less for several weeks, and in some 
cases three or four months, when suddenly without any known cause, the 
little patient is seized with a general convulsion, which may be repeated 
at short intervals two or three times, or may occur but once. This is fol- 
lowed by a more continuous moderate grade of fever, with headache, some 
contraction of the pupils, inability to be up, indisposition to talk except 
when directly questioned, little or no appetite, often vertigo and disposi- 
tion to vomit when the head and trunk are raised to an upright position; 
pulse and respiration are variable, generally increased in frequency when- 
ever the patient is disturbed, but slower and occasionally intermitting 
when quiet in a recumbent position. In from five to seven days after the 
patient is compelled to remain in bed, he becomes more dull and somno- 
lent, his pupils more dilated, and often the neck stiff, or the head turned 
to one side; the pulse weaker and more frequent, respiratory movements 
feeble with an occasional sigh, deglutition impaired, bowels inactive, and 
abdomen apparently empty, there being neither distension nor tympanitis. 
In the early part of this stage, the patient can be aroused by shaking or 
sharp questioning sufficient to recognize those speaking to him and an- 
swer in monosyllables; but if the answer requires the use of sentences, he 
will generally lose the thought, and leave the sentence unfinished. The 
supervention of these symptoms indicate the commencement of serous ef- 
fusion and consequent pressure upon the surface and the lateral ventricles of 
the brain. The s\ r mptoms resulting from such pressure usually increase 
from day to day, until consciousness is entirely lost; the discharges invol- 
untary; the limbs motionless; the eyelids only half closed; pupils widely 
dilated, and the exposed surface of eyeballs dry, with a little mucopuru- 
lent or opaque matter in the inner angle; pulse small, weak, and variable 
in frequency; respiratory movements extremely feeble, with an occasional 
interruption, followed by a sigh or deeper inspiration; and no attempt at 
deglutition. In from one to four or five days after the development of 
these symptoms, a little coarse mucous rattle is heard in the trachea and 
larger bronchial tubes for a few hours, when generally one or two slight 
convulsive shudders run through the muscular system, the chin drops, the 
tongue falls back in the mouth, a few feeble gasps for breath, and life is 
extinct. Such is the most common course of the disease as met with 
in children between the ages of one and seven years. It is sub- 
ject, however, to many variations. I have seen children of a 
strong hereditary tubercular diathesis, who were subject to periods 
two or three times a year, lasting two or three weeks at a time, during 
which they would present all the premonitory symptoms I have just de- 
tailed, including one or more convulsive paroxysms, yet so far recover as 
to appear bright and quite well in the interval. In almost all cases, how- 
ever, the symptoms of the second, followed by those of the third stage, 
came on before the end of the second year. These illustrate the more 
chronic form of the disease. On the other hand, I have seen cases so rapid 
that after the symptoms of disturbed sleep, sudden startings, with moder- 
ate gastric and intestinal disturbances had lasted but two or three days, 
more continuous fever supervened accompanied by drowsiness, inattention, 
variable pulse and respiration, with first contracted and subsequently di- 
lated pupils, and all the symptoms of cerebral pressure increasing so rapidly 
as to prove fatal in from five to seven days from the first appearance of 



SYMPTOMS. 329 

symptoms sufficient to attract attention. In adults and children over ten 
rears of age, the disease is less frequently accompanied by convulsions 
during any stage of its progress, and more uniformly continues until a 
fatal result is reached without intervals of partial recovery. But when the 
inflammatory action commences in the pia mater before the cranial sutures 
and fontanelles have closed, these open, allowing the head to enlarge as 
the effusion accumulates, thereby lessening the direct pressure on the 
cerebral structure, and thus enabling the patient to live for months and 
sometimes several years. It is but a few weeks since, that 1 called your 
attention to a case of this kind in one of the hospital clinics. The head 
of the child was increased in both the vertical and transverse diame- 
ters, making the top and anterior part of the head look high and broad, 
with the anterior fontanelles prominent and at least fifty millimeters (two 
inches) in diameter, while the eye-balls appeared to be crowded a little 
outward and downward, giving both to the face and head a peculiar and 
characteristic appearance. That child was eighteen months old, the symp- 
toms of meningitis having commenced at the age of six months. While 
the head had thus increased in size, the body and extremities were emaci- 
ated and the muscles of the neck hardly strong enough to hold the head 
erect. Neither would its limbs support the weight of its body; and yet it 
gave evidence of considerable mental activity and intelligence. A few 
years since I had the opportunity of presenting to the clinical class a girl 
aged seven years, whose history, as related by her mother, showed an at- 
tack of subacute meningitis with one or two convulsions when the child 
was only two months old; after which the head continued steadily but 
slowly to increase in size until the time I presented her to the clinical 
class. At that time the sagital and coronal sutures were wide open, the 
anterior fontanelle at least seventy-five millimeters (three inches) in diam- 
eter, and the whole head enlarged in the same proportion. The eye-balls 
were prominent and turned obliquely downward, from the depression of 
the superior orbital plate of the frontal bone, while the small face tapering 
to the chin contrasted strongly with the broad and high forehead. The 
body and extremities were emaciated and small, making the head look 
larger and feel heavier than the whole body. She could move all her limbs, 
but had not strength to turn her head, much less to lift it from the pillow. 
When allowed to remain quiet in a strictly horizontal position, she took 
food and drink when offered to her and manifested some degree of intelli- 
gence. But the moment her head was raised up sufficient to bring the 
pressure of the contained fluid upon the medulla oblongata and parts at the 
base of the brain, the whole system of voluntary muscles would become 
tremulous, the circulation and respiration irregular, and unless speedily 
returned. to the horizontal position, more decided convulsive movements 
ensued. She died in the eighth year of her age. 

These cases sufficiently illustrate the course of chronic meningitis com- 
mencing in early infancy, whether connected with tubercular deposits or 
not. The chronic form of the disease occurring at any age after the 
cranial sutures and fontanelles have closed, if accompanied by serous 
effusion, must necessarily cause compression of the brain, and its conse- 
quences, as I have already described. There is, however, a grade of chronic 
meningitis that is not accompanied by serous effusion or symptoms of com- 
pression, but simple hyperemia of vessels with plastic deposits and thicken- 
ing of some portions of the membrane. The early symptoms of such cases 
are almost constant cephalalgia with sensations of undue heat and fullness 
in the head, frequent flushing of the face, slight acceleration of the pulse, 
inability to sleep, undue sensitiveness to light and sound, great mental 



330 CEREBRITrS. 

excitability, and at a later period more constant mental derangement. This 
form of meningitis is so closely connected with some of the forms of in- 
sanity that its diagnostic symptoms will be more fully considered in con- 
nection with that subject. 

Cerebritis. — When acute or subacute inflammation attacks the interior 
portions of the brain without involving the surface or gray matter of the 
convolutions, the symptoms differ in some respects from those of menin- 
gitis. The initial symptoms are generally vertigo, or a. disposition to go or 
fall in a certain direction when in the erect position, accompanied by a 
disposition to vomit, and in some cases chilliness and cold extremities. 
These symptoms are followed by general fever and pain in the head, but 
the former is not as ligh and the latter is more circumscribed or limited 
to some one part of the head, than in meningitis. Instead of the intense, 
throbbing, distracting pain over the whole head, in cerebritis the pain is 
sharp, often running through the head like a knife, but so limited in space 
that the patient claims he can cover it with his finger. I nstead of early 
and excited delirium the mind appears dull, taciturn, indisposed to talk, 
and the patient turns or moves his head with reluctance. In the early 
stage the pupils are contracted, but not always equaliy so, and in many 
instances there is rigidity of some of the muscles of the neck or extremities 
or hyperesthesia of the surface. In children the thumbs are sometimes 
drawn into the palms of the hands and the fingers bent over them from 
tonic contraction of the muscles of the forearm. More rarely the toes and 
feet are affected in a similar manner. The temperature seldom rises above 
39° C. (102.5° F.); the pulse is small and corded, but very variable in 
frequency, in some cases being slower than natural and the respirations 
altered in the same direction. The duration of this first stage varies in 
different cases from three to seven or nine days, during which time the 
abdomen appears empty and the bowels decidedly costive. Sooner or 
later the mind becomes more dull or wandering and difficult to arouse; one 
or both pupils begin to dilate; the respiration and circulation are more 
variable and often intermitting; deglutition slow and difficult; the 
muscles previously rigid become relaxed, constituting paralysis; and the 
evacuations either become involuntary, or the urine is retained until the 
bladder is over-distended. In this condition the patient lingers from one 
to two weeks and dies in an unconscious and paralyzed condition. In the 
more acute cases the disease will run through its regular stages of intense 
capillary congestion, exudation and fatal compression in one week, while 
the subacute cases may occupy from four to six weeks in reaching the 
same result. You will thus observe that the usual course of cerebritis is 
slower than that of meningitis, and the accompanying symptoms less 
violent and in some respects more resembling those of typhoid fever, for 
which it has been sometimes mistaken. The particular part of the brain 
involved in the inflammation in any given case is often clearly indicated 
by the presence of special symptoms. Aphasic symptoms or early loss of 
speech, points to disease of the inner part of the anterior lobes, or more 
particularly to the island of Reil. Early derangements of, or loss of vis- 
ion, indicate disease near the tubercula quadrigemina, while early and 
prominent disturbances of muscular action, as manifested either in spasms, 
muscular rigidity, or inco-ordination of movements, point to the cerebellum 
or medulla oblongata, as the seat of disease. 

Cerebral Sclerosis. — There is one more form of inflammation occasionally 
met with affecting the structure of the brain. Its primary seat is the con- 
nective tissue, which under chronic inflammatory irritation becomes hyper- 
trophied and consequently so presses upon the nerve cells and fibres as 



CEREBRAL SCLEROSIS. 331 

to interrupt their nutrition and cause their ultimate disappearance, leav- 
ing the texture of the part harder than natural. These cases of disease of 
the brain are strictly analogous in their pathology to the slow interstitial 
inflammation that leads to sclerosis of the connective tissue of the lungs, 
Liver, and kidneys, as seen in what some have called fibroid consumption, 
cirrhosis, and the hard granular kidney. Hence it has been called 
cerebral sclerosis. This affection is always chronic, and its clinical history 
extends over several years. I have one case now under observation that 
has already continued fifteen years; but most of the cases terminate in 
from five to ten years. The most characteristic symptoms are mental de- 
spondency, with impairment of the mental faculties generally, but more 
in the direction of enfeeblement than of perversion or derangement; a pe- 
culiar fixedness of the position of the head in walking, generally leaning it a 
little forward or to one side, with a slightly tremulous or unsteady condition 
of the voluntary muscular movements; and as the disease advances, the mus- 
cular rigidity or paralysis affects successively different sets of muscles in 
such order of succession, as to indicate quite clearly the progressive ex- 
tension of the disease in the cerebral structure. A constant dull pain ex- 
tending from the occipital to the lower part of the frontal region, through 
the base of the brain, increased by motion, is a pretty constant accom- 
paniment of the disease; as is also insomnia and great restlessness at 
night. In the advanced stage of the disease the muscles concerned in 
speech and deglutition, become so impaired in their action as to render 
both these acts slow and difficult. And' if the patient gains an upright 
position he is disposed to move in some special direction in spite of his 
efforts, or if he progresses forward, it is only by a trotting gait with the 
head and body leaning in that direction. 

In most of this class of patients the appetite and general nutrition con- 
tinue good. Consequently there is little or no emaciation, and in some 
cases a positive increase of fat and weight. More or less fatty degenera- 
tion generally accompanies the pathological changes in the brain, and the 
mental faculties ultimately become so impaired as to constitute decided 
dementia; and death finally results from the haemorrhagic extravasations, 
causing general paralysis or apoplexy. 

Cerebral sclerosis is very generally connected with similar pathological 
changes in some part of the medulla and spinal cord. Of the symptoms 
indicating the existence of the latter, I shall speak when considering the 
inflammations of the cord generally. As the present hour has expired, I must 
reserve the consideration of the morbid anatomy, diagnosis, and treatment of 
the different grades of meningitis, cerebritis, and cerebral sclerosis until 
we meet to-morrow. 



LECTURE XXXV. 

Inflammation of the Brain, e f c, continued— Meningitis, Cerebritis, Cerebral Sclerosis; Their 
morbid Anatomy, Diagnosis, and Treatment. 

GENTLEMEN: At the close of the preceding lecture hour I had com- 
pleted what was deemed necessary to say concerning the clinical 
history or symptomatology of the different grades of inflammation affect- 
ing the membranes and structure of the brain. As I explained fully 
when speaking of the general pathology of inflammation, the first stage is 



332 TATHOLOGY OF MENINGITIS, ETC. 

characterized by intense vascular fullness with increased excitability of 
the inflamed part. In all oases, therefore, in which death has taken place 
during the first stage of either meningitis or cerebritis, a post mortem ex- 
amination of the inflamed structures shows complete engorgement of the 
capillaries and smaller vessels with correspondingly increased redness, 
and some disturbance of the molecular arrangement of corpuscles and or- 
ganic atoms, both in the contents and walls of the vessels. When death 
has taken place during the second or third stage, you find, in addition to 
the redness and intense vascular fullness, more or less exudation of the 
contents of the vessels both into the interstitial spaces and upon the 
surface of the inflamed part. If the case is one of meningitis or inflam- 
mation of the pia mater and surface of the convolutions, you will generally 
find a stratum of serous fluid over the surface of the membrane, in the 
lateral ventricles, between the convolutions, and to some extent in the 
interstitial spaces of the gray matter under the membranes. 

This serous fluid has escaped from the over d'stended vessels and con- 
tains, besides the water, more or less albumen, shreds of fibrin, white and 
red corpuscles, and sometimes numerous pus cells. The amount of fluid 
varies much in different cases. In some of the more active cases in pa- 
tients with previous plastic blood, numerous patches of thin pseudo-mem- 
branous exudation have been found on the surface of the pia mater. 

In the tubercular form of meningitis the amount of serous effusion is 
generally larger than in simple inflammation, but the fibrinous or plastic 
elements are less. The chief structural peculiarity of these cases, howev- 
er, is the presence of small gray miliary tubercles chiefly in the pia mater, 
but often also in the arachnoid and in the gray matter of the cerebral con- 
volutions. They are found in greatest number usually in the membrane 
covering the under surface of the cerebellum and posterior lobes of the 
cerebrum, in the fossa Sylvii, and neighboring parts, but are also sometimes 
found over the cerebral hemispheres, and in the choroid plexus. Many of 
the granules are very small, but when several are aggregated together 
they may make a nodule the size of a small pea. Examined under the 
microscope they are found to consist of lymphoid cells collected in nodules 
in the walls of the small arteries of the pia mater and surface of the brain. 
The large granular or giant cell is rarely seen, and appearances of caseous 
degeneration in the center of these small tubercles is less observable than 
in tubercular deposits elsewhere. The serous part of the effusion in this 
class of cases is found mostly under the base of the brain and in the lateral 
ventricles, and often contains pus cells enough to give it a turbid appear- 
ance. 

In cerebritis or inflammation of the interior part of the brain, there is a 
decided tendency to suppuration and the formation of abscesses. In 
some cases the collections of pus are small and numerous, with the vessels 
of the surrounding brain structure finely injected with blood and the in- 
terstitial spaces crowded with serous fluid containing pus corpuscles, giv- 
ing it an cedematous and somewhat softened appearance. Small hemor- 
rhagic exudations into the perivascular sheaths, with broken nerve fibres 
and fatty degeneration of the ganglion cells, are also observable in most 
cases. Instead of numerous small abscesses, cases occasionally occur 
with but one abscess and that of large size. 

In all recent cases the walls of the abscess are fringed or shaggy and 
destitute of a lining membrane. But in more protracted or chronic cases 
the walls of the abscess are generally lined with a layer of condensed con- 
nective tissue somewhat resembling a cyst, and the matter may emit an 
offensive odor. When death has taken place early, there may be no wel 



DIAGNOSIS. 333 

defined abscesses, but the inflamed structure when cut across, will pre- 
sent numerous points of blood from the engorged vessels, a reddish yellow 
color of the surface, and some interstitial infiltration of the liquor san- 
guinis. 

In the cerebral sclerosis, the chief pathological changes are, the hyper- 
plasia or increased growth of the connective tissue and the coincident 
diminution of the nerve cells with more or less fatty degeneration of 
such cells as remain. This gives greater density or induration to the 
affected brain structure, instead of softening, as in ordinary cerebritis. 
The seat of this form of disease is generally in the white or medullary 
part of the brain, and is very generally confined to particular tracts or 
bundles of nerve fibres, and may be traced through the medulla down 
the spinal cord. 

Diagnosis. — The diagnosis of simple acute or subacute inflammation 
of the membranes and surface of the cerebral hemispheres, to which I have 
applied the name of meningitis, is not difficult. The severe distracting 
pain and unusual heat in the head, the fullness of the carotid and tempo- 
ral arteries, the contraction of the pupils, the increased sensibility to light 
and sound, and the general nervous and mental excitement, constitute an 
assemblage of symptoms that sufficiently indicate the early stage of this 
disease; while the subsequent stupor, dilated pupils, variable pulse, sigh- 
ing respiration, and paralysis, still more strikingly characterize the later 
stages of its progress. 

The milder cases of the subacute and those of the tubercular form, require 
closer attention to prevent mistakes during the early stage of their prog- 
ress. The nervous symptoms accompanying these cases, such as sudden 
startings, crying out in sleep, and even the convulsions, are very often 
attributed to teething, if the patient is under two years of age, and to 
worms, if older. 

So, too, the sudden turns of paleness and vomiting, followed by feverish- 
ness with the variable condition of the intestinal discharges already 
described, are attributed either to the same causes or to gastro-intestinal 
irritation. There is, however, in all these cases of meningeal disease, a 
continued sadness of expression, a carefulness in the movements of the 
head, an alteration in the size of the pupils, and a lankness of the abdo- 
men or absence of flatulent distension, that I have never seen in connec- 
tion with intestinal worms or any other form of gastro-intestinal irritation. 
It only requires careful and discriminating attention to the history and 
detail of symptoms in each case to avoid mistakes in the diagnosis, even 
in the first stage of the disease. 

The only disease with which cerebritis has been confounded, is typhoid 
fever. There is a certain degree of similarity in some of the symptoms, 
such as the dullness and indisposition to talk freely, the vertigo or un- 
steadiness of the head in the upright position, and the low grade of fever. 
But close attention will develop the fact that in the cerebral disease, the 
pain in the head is more circumscribed and penetrating; one or both pu- 
pils are contracted, and the eyes unduly sensitive to light; a disposition is 
manifested to keep the head in a fixed position, or if moved, to have an in- 
clination to fall in a given direction; the bowels are not only costive, but 
requiring full dosos of cathartic medicines to move them; and the abdo- 
men is free from tympanites or fullness from any cause. These are all re- 
versed in the early stage of typhoid or any other general fever. As the 
cerebral disease advances, the further alteration of the pupils, the occur- 
rence of rigidity in the muscles of the neck or extremities, the increasing 
stu or or difficulty of speech, and the continued lankness or retraction of 



'334 MENINGITIS, ETC. 

the abdominal muscles, ought to be regarded as sufficient to remove all 
doubts concerning the diagnosis. The detail of symptoms I gave in the 
preceding lecture as accompanying cerebral sclerosis, are sufficiently di- 
agnostic of that form of disease, and need not to be repeated here. 

Prognosis. — All cases of inflammation involving either the pia mater, 
cerebral convolutions, or interior structure of the brain, are more or less 
dangerous to life. In simple, acute and subacute meningitis, as I described 
it in the preceding lecture, if the diagnosis is made early, and the treat- 
ment promptly and accurately adjusted during the first stage of the in- 
flammatory process, there is a reasonable probability of success in arresting 
the disease before any considerable amount of exudation or effusion has 
taken place, and the patient will recover. Such a result has been ob- 
tained in many cases under my own observation. If the first stage has 
passed, and symptoms of effusion or exudation already exist, the progno- 
sis must be regarded as decidedly unfavorable, although occasionally a 
case may recover by the absorption of the inflammatory products. When 
meningitis or cerebritis occurs in a patient of decided scrofulous or tuber- 
culous diathesis, and especially if tubercular deposits already exist, it is 
not probable that a permanent recovery ever takes place. 

I have many times seen mild inflammatory attacks in such cases prompt- 
ly checked by proper treatment, but the disease has always returned, and 
ultimately proved fatal. 

Cerebral sclerosis, when well established, is also uniformly fatal, but in 
most cases not until after a period of suffering, varying from five to fifteen 
years. 

Treatment. — The delicacy of structure and high degree of vascularity 
of the brain and its immediately investing membrane, together with the 
fact that after the early months of infancy the whole is inclosed within 
the bones of the cranium in such manner as to allow of little or no expan- 
sion from increased fullness of blood, makes that element of the first 
stage of the inflammatory process which I have sailed hyperemia or accu- 
mulation of blood in the inflamed part, one of paramount importance in 
the diseases now under consideration. In all the more acute inflammatory 
attacks, whether involving the membranes or substance of the cerebral 
hemispheres it is the pressure, first from the over-distended and engorged 
blood-vessels, and second, from the accumulation of inflammatory products, 
that constitutes the chief danger to the life of the patient. Consequently, 
it is of great importance to commence the treatment of all such cases as 
soon after the commencement of the attack as possible, and to use such 
remedies promptly as will be most efficient in lessening the accumulation 
of blood in the part. By so doing we shall not only lessen the danger of 
fatal pressure from the direct engorgement of vessels, but we shall most 
effectually limit the amount of inflammatory products in the form of exu- 
dations and effusions. For it matters not, gentlemen, what theory of in- 
flammation you adopt, the clinical fact remains that you get no inflammatory 
products, whether in the form of cell-proliferation, migrating corpuscles or 
leucocytes, micrococci, or exuded liquor sanguinis, until you first have 
undue vascular fullness or accumulation of blood and irritation of structure; 
and the additional fact that the further accumulation of such products 
ceases as soon as the vascular fullness is removed. Therefore I repeat 
with emphasis, that the leading object to be accomplished in the treat- 
ment of the first stage of cerebral inflammation is to relieve the undue 
accumulation of blood before a dangerous degree of exudation has taken 
place, and so far as may be practicable to coincidently lessen the morbid 
excitability of structure. If you succeed fully in accomplishing this ob- 



TREATMENT. doO 

joct you prevent the second stage, and it is only necessary to continue 
those measures that are calculated to lessen irritability and prevent a re- 
newal of blood accumulation, for a few days, and convalescence will be 
established. If, however, the effort to relieve the hyperemia of the first 
staie has been only partially successful, and the second stage accompa- 
nied by more or less exudation, whether plastic or serous, has supervened, 
then the principal objects to be accomplished by further treatment, are, to 
sustain the patient and hasten as far as possible the removal of the exuda- 
tive products by disintegration and re-absorption. 

I state thus distinctly the objects desirable to accomplish in the treat- 
ment of the successive stages of both meningitis and cerebritis, because 
they are founded on the nature of the inflammatory process and the ana- 
tomical characteristics of the structures involved, and will always remain 
the same. The relative value of the therapeutic agents designed to ac- 
complish any given object, may change with every addition to our knowl- 
edge of new remedies or of the modus operandi of old ones, but the 
object itself will stili remain. 

In addition to a definite knowledge of the objects to be accomplished, 
it is desirable that you have an equally clear comprehension of the modes 
by which they may be effected. For instance, the accompl shment of the 
first object I have named, may be reached either by the use of remedies that 
reduce the force and frequency of the action of the heart, and thereby lessen 
the quantity of blood sent to the inflamed part in a given time; or by the re- 
moval of a quantity of the blood itself sufficient to lessen the general full- 
ness, as by venesection and leeches; and by such as are capable of induc- 
ing contraction of the hyperaemic vessels themselves. In other words the 
amount of blood in the vessels and capillaries of a part, may be influenced 
by cardiac sedatives, direct depletion, and vasomotor excitants or tonics. 
The relative value and applicability of each of these classes of remedies 
in any given case must depend upon the special character of the inflam- 
mation as influenced by the quality of the blood and the elementary prop- 
erties of the structure involved. In acute active inflammation of the 
membranes and structure of the brain, in subjects not previously debili- 
tated by specific causes, the prompt abstraction of a liberal quantity of 
blood by one free bleeding in adults and by leeches in children, aided by 
the judicious use of cardiac sedatives, is by far the most efficient mode of 
checking or arresting the inflammatory process in its first stage, that can 
be devised. That many of the milder class of cases can be controlled by 
the sedatives without the loss of blood has been proved by clinical epe- 
rience. 

But in my estimation the same kind of experience has equally proved 
that in the more acute and active cases the danger to the life of the pa- 
ixent is greatly increased by such omission. Bleeding should be resorted 
to only during the stage of active excitement, before any symptoms of ex- 
udation or effusion are manifest. Elevate the head and shoulders of your 
patient a little, cord the arm and make an opening in the vein sufficient 
to allow the blood to flow in a free stream, and let the flow continue until 
the pulse becomes soft, the face free from flush, and small drops of sweat 
appear on the forehead. When you get these effects, lower the head and 
shoulders more nearly to the horizontal, loosen the cord upon the arm lit- 
tle by little so that the flow of blood stops rather gradually instead of sud- 
denly, dress the arm by a compress over the incision and a bandage to 
keep it in place. If the bleeding has been continued until the effects I 
have mentioned have been produced, without regard to the mere quantity 
of blood taken, you will find it immediately followed by general moisture 



336 MENINGITIS, ETC. 

of the skin, sometimes faintness or a momentary approach to syncope, and 
great relief to the pain in the head. The amount of blood required to be 
taken to produce a given effect, differs much in different patients. I have 
seen some patients with meningitis from whom I was compelled to ab- 
stract one litre (^xxxii) of blood to obtain the same effect on the circula- 
tion and general condition of the patient, as I have obtained in other 
cases of the same disease by taking only half that quantity (§xvi). By 
one prompt, free bleeding, as I have described, you directly lessen the 
force of the heart's action, diminish the general vascular fullness, and 
make the blood less stimulating by materially diminishing the relative 
proportion of its red corpuscles. To hold the advantage you have thus 
gained, you should, even while the blood is flowing, or as soon after as 
possible, commence the administration of cardiac or arterial sedatives, ap- 
ply warmth to the extremities andan N ice cap to the head, and in an hour 
after the first dose of the sedative, give a full cathartic of calomel and 
jalap. If it does not move the bowels freely in three or four hours, hasten 
the action by from eight to twelve grams (3ii to 3"i) of sulphate of mag- 
nesia, or an enema of warm saltwater sufficient to fill the rectum. 

In the mean time the windows should be a little shaded and the sick 
room kept as quiet as possible and the doses of the sedative repeated every 
two hours until the frequency of the pulse is reduced nearly to the natural 
standard, and then so graduated as to time and quantity as to hold this 
control over the circulation without inducing vomiting. The sedative 
which I prefer for this purpose is the saturated tincture of veratrum viride 
in doses, for adults, of 0.25 to 0.33 c. c. (min. ivto v) every two, three, or 
four hours as may be found necessary to produce the desired control over 
the circulation. In some cases accompanied by great nervous disturbance 
and delirium, I have thought better effects were obtained by a combination 
of one part of the tincture of veratrum viride with two parts of the tincture 
of gelsemium, given in doses of 0.6 to 1.0 c. c. (min. x to xv) every three 
or four hours. Of course these doses must be reduced in treating children, 
to correspond with the age of the child. All the remedies I have now in- 
dicated should be made to follow the bleeding as quickly as possible and 
their effects carefully noted that in dose and time of administration they 
may be kept accurately adjusted to the condition of the patient. After 
the bowels had been freely moved b} 7 the cathartic, in severe cases, I have 
given alterative doses of calomel between the doses of veratrum for twen- 
ty-four hours and followed them by a saline laxative sufficient to produce 
a moderate evacuation of the bowels. 

In a large proportion of the cases in which the measures I have indicated 
were commenced early and prosecuted judiciously, the disease was ar- 
rested, or the symptoms so much relieved as to obviate danger to life be- 
fore the end of the third day, and an early convalescence followed. If, in- 
stead of this, however, symptoms of commencing effusion or exudation are 
developed as I described when speaking of the symptoms which mark the 
beginning of the second stage of the inflammatory process, the cardiac 
sedatives should be promptly discontinued or much reduced in quantity, 
and fair doses of iodide of potassium substituted in their place. The 
following formula is one of the most efficient that I have used at this 
critical stage of the disease: 

~fy Potassii Iodidi 10.00 grams 3iiss 

Tincturae Digitalis 15.00 c. c. 3iv 

Tincturas Hyoscyami 15.00 u " 3iv 

Aquae Mentha? 90.00 « " g i ii 



TREATMENT. 337 

Mix. Give four cubic centimeters (fl. 31) every two or three hours, in 
a little sweetened water. At the same time blisters may be applied to 
the mastoid spaces or back of the neck, or to both; and the cold appli- 
cations to the head allowed gradually to increase in temperature until 
they become decidedly warm instead of cold. Sometimes these measures, 
if brought into requisition at the beginning of the transition from active 
excitement and hy perse mia to that of depression and exudation, will check 
the progress of the latter in time to prevent entire stupor and paralysis, 
and the patient will slowly recover. But they often fail and the fatal re- 
sult soon follows. 

In many of the milder cases, both of meningitis and cerebritis, the free 
application of leeches to the temples and mastoid regions may take the 
place of the first general bleeding. The same remark is applicable to the 
more active cases of tubercular meningitis; while the milder cases of this 
class are better intrusted to the cautious use of cardiac sedatives, iodides, 
hyoscyamus, and blisters, without the loss of blood by either leeches or 
venesection. 

If the disease assumes a chronic form with effusion and enlargement of 
the head, as it often does when the attack occurs in infancy, I have seen 
more benefit from the protracted use of moderate doses of iodide of potas- 
sium, internally, and the repeated application of small blisters over the 
mastoid spaces, than from any other remedies. In such cases the diet 
should be simple and easily digested, yet sufficiently nutritious to sustain 
the patient. 

During the first stage of active excitement in ordinary cases of acute 
cerebral inflammation, the patients need no other nourishment than toast- 
water or thin gruel, and in the latter stages milk in small doses. During 
convalescence the nourishment should still be mild and unstimulating, the 
exercise very moderate, with a careful avoidance of all mental excitement 
or active mental application. 

In cerebral sclerosis or chronic inflammation of the connective tissue in 
certain portions of the brain, no remedies have been found to possess any- 
certain control over the progress of the disease. In the cases that have 
come under my own observation, I have obtained more benefit from the 
protracted use of a combination of iodide of sodium, bichloride of mercury, 
and conium, than from all other remedies. The following is a convenient 
formula for its administration: 

# Sodii Iodidi 12.000 grams 3iii 

Hydrargyri Chloridi Corosivi 0.066 " gr. i 

Extracti Conii Fluidi 15.000 c. c. 3iv 

Elixir Simplicis 105.000 " " §iiiss 

Mix. Give four cubic centimeters (fl. 3i) at breakfast, noon, tea- 
time and at bed-time, in a little water. 

You may say that the iodide and the mercurial in this prescription 
unite and form an iodide of mercury, and ask me why I do not prescribe 
the latter directly. I answer that the sixty-six milligrams of corrosive chlo- 
ride can combine with only a very small part of the twelve grams of iodide 
of sodium, and that the excess of the latter constitutes a very important 
part of the prescription. And numerous trials have shown that the admin- 
istration of the iodides of mercury alone do not produce the same degree 
of benefit as when combined with the excess of iodide of sodium as in the 
prescription just named. 

22 



338 CEREBRAL SCLEROSIS. 

Patients who have not acquired a previous undue susceptibility to the 
influence of mercurials can generally continue the use of this combination 
several weeks without affecting the mouth or gums. Still the effects of 
mercurial preparations in this direction should be watched with reasonable 
care. 

Some of the cases coming under the head of sclerosis are closely allied 
to, if not identical with, chronic rheumatic inflammation. In such, some 
benefit may be derived from the use of fair doses of salicylate of sodium 
or bromide of lithium, more especially if given in connection with the 
tincture or fluid extract of the phytolacca decandra. The phosphide of 
zinc (Dr. Flint), the chloride of barium (Dr. Hammond), and the nitrate 
of silver have been occasionally used with advantage and recommended 
by men of eminence. When, as is often the case, the patient suffers from 
much pain and restlessness during the night, a single dose of bromide of 
potassium or ammonium and hydrate of chloral, one to two grams each (gr. 
xv to gr. xxx) given about eight o'clock in the evening, will often pro- 
cure rest for the night. Many recommend the bromides, and use them 
in full doses in the active stage of the more acute cerebral inflammations. 
While I have found these agents of very great value in allaying nervous 
hyperesthesia and insomnia, I have not been fortunate enough to obtain 
much effect from their administration in any stage of active inflammation. 
And in a few cases, in which the attending physician had continued their 
use after the mental dullness or partial stupor had appeared from the ac- 
cumulation of inflammatory products, the effect appeared to be injurious 
by adding to the depression. I have seen a few cases, both in children 
and adults, in which depletion and cardiac sedatives had relieved the ac- 
cumulation of blood and effectually checked the tendency to effusion, yet 
the patients continued restless, wakeful, and the special senses morbidly 
acute, with a soft but quick or irritable pulse. In thete. giving fair doses 
of some reliable preparation of ergot alternately with the iodide of potas- 
sium, and a dose of the compound powder of opium and ipecacuanha, 
(Dover's powder), in the evening, has had a very happy effect. In such 
cases, the morbid excitability and impaired tonicity of the structure re- 
mains after the actual hyperemia has been relieved. Consequently, the 
ergot, aided by the opiate at night, exactly meets the indication, and much 
relieves the patient; when further cardiac sedatives or depletion would 
only have increased his suffering, and endangered ultimate exhaustion and 
fatal collapse. 

Convalescence. — The stage of convalescence following all grades of in- 
flammation of the hemispheres of the brain and their investing membranes, 
is one of much practical importance, on account of the readiness with 
which the local hyperemia and excitement may be rekindled by either 
mental or physical-activity. It makes it necessary that the patient should 
not resume active exercise either of body or mind until the general tone 
of health is well restored; and even then, the resumption of exercise should 
be very gradual, with frequent intervals of rest. The diet, for several 
weeks, should be chiefly of milk, farinaceous articles, the lighter vegeta- 
bles and fruits, with but little meat. In those cases of scrofulous and tu- 
berculous meningitis in which one attack is recovered from, as often 
happens, it is not only necessary to take all the precautions I have just in- 
dicated during the ordinary period of convalescence, but all those means 
for counteracting the faulty constitutional condition and tendencies, which 
were urged upon your attention in the lecture on the treatment of scrofula 
should be diligently used for months or even years with the hope of pre- 
venting a renewal of the local inflammation. Special care should be 



CEREBROSPINAL MENINGITIS. 339 

taken to prevent parents and teachers from allowing children of this class 
to applv the mind too intently or persistently in the process of education. 

Neither should their physical exercises be too exciting or protracted. 
The aim should be to give such patients that habitual moderate out-door 
exercise that promotes nutrition and muscular strength, without positive 
fatigue or exhaustion; and that degree and kind of mental occupation 
which favors cheerfulness and mild discipline without high excitement, 
anxiety, or intensity of application. 

And do not forget that, in all directions for physical exercise to this 
class of subjects, the muscles of the arms and chest need quite as much 
discipline as those of the lower part of the trunk and legs. 



LECTURE XXXVI. 

Cerebro-Spinal Meningitis— Sporadic and Epidemic Spinal Manin^itis ; Myelitis, and Spinal 
S3lerosis; Their History, Causes, Symptom;, .Morbid Auatomy,.DiagnDsLs, Prognosis, and Treatment. 

GENTLEMEN": Ordinary sporadic attacks of inflimmation located in the 
membrane and under surface of the brain, including the med- 
ulla oblongata and its junction with the spinal cord, and constituting 
cerebro-spinal meningitis, are not of very frequent occurrence at any 
period of life, but are met with more frequently among children than 
adults. They m ly arise from the same causes, and under the same cir- 
cumstances, as inflammation of the pia mater and surface of the convex 
part of the hemispheres. The symptom?, progress and results differ from 
those accompanying inflammation of other parts of the cerebral surface, only 
on account of the difference in the functions performed. The intimate 
connection of the m 3duila and gray misses near the b ise of the brain 
with the nerves of special sense and those controlling respiration anl cir- 
culation, is such that any inflammatory action set up in those parts, more 
speedily disturbs the hearing, vision, and respiratory movements, and in 
consequence of the latter, more frequently leads to an early fatal termi- 
nation. 

Symptom*. — Acute attacks are generally ushered in by a brief period 
of paleness, coolness of the surface and extremities, vertigo, one or two 
sudden turns of vomiting, immediately followed by intense pain in th ; 
occipitofrontal region through the base of the brain, buzzing or nois >s 
in the ears, flashes of light or dimness of vision, increased heat, flush of 
the face, contraction of the pupils, frequency and fullness of the pulse, 
retraction of the head from rigidity of the muscles of the posterior part of 
the neck, hurried breathing, and more or less delirium. In from six to 
twelve hours the hearing and vision are both suspended; one or both 
pupils begin to dilate, and the eyeballs to be turn ;d from their natural 
direction and parallelism; the mental faculties more dull; the head more re- 
tracted, either directly backward or obliquely toward one side; frequent 
automatic movements of the extremities; respiration irregular with fre- 
quentsighing; pulse variable in frequency and sometimes intermitting, but 
retaining its volume and a fair degree of force, while the renal and all 
other secretions are mach diminished. If the attack is severe and not 



340 CEREBROSPINAL MENINGITIS. 

moderated by treatment, in from twelve to twenty-four hours more, the 
automatic movemen s of the extremities will have ceased trom the super- 
vention of paralysis; the face will appear less flushed; the pupils more 
completely dilated; the intestinal discharges involuntary, and the renal 
secretion suppressed; the pulse smaller, weaker, and more irregular; res- 
piration sometimes hurried and panting, at other times slow, weak, and 
intermittent; deglutition either difficult or altogether losr, and the mind 
either wandering or comatose. A little later, the increasing paralysis of 
the muscles of deglutition and respiration permits the mucus to accumu- 
late in the air passages, causing coarse mucous rales, soon followed by 
death. You observe in this description of the symptoms, the same stages or 
order of phenomena as in the acute meningitis, already fully considered. 
First, a brief period of intense injection of the vessels with high excite- 
ment; second, a period of transition, during which exudation or eifusion 
is taking place, causing the contracted pupils, excited delirium, frequent 
and full pulse to give place to dilatation, dullness, variable pulse, etc.; 
and third, the period of general failure of functional action, or paralysis. 
These several stages are accompanied by the same pathological changes, 
and followed by the same kind of post mortem appearances in the mem- 
brane and surface of the base of the brain and medulla oblongata, as I 
pointed out to you when speaking of the results of inflammation of the 
membranes and surface of the upper part of the cerebral hemispheres. 

Diagnosis. — The special symptoms which serve to distinguish inflam- 
mation of the base of the brain and medulla oblongata from all other affec- 
tions, either of a functional or inflammatory character, are the rapid devel- 
opment of disturbances of respiration, hearing, seeing, muscular contrac- 
tions and rigidity, especially in the posterior cervical region, in direct 
connection with intense pain in the head, and general fever. Mere reflex 
or functional disturbances are not accompanied by the rapid rise of tem- 
perature and increased tension of the carotid and vertebral arteries which 
mark the first stage of the inflammation; and when the latter attacks other 
parts of the brain and its membranes, the contraction of the cervical mus- 
cles, retracting the head, and the loss of vision and hearing, supervene at 
a later stage in the progress of the case, are generally less prominent, and 
sometimes absent, or nearly so. 

Prognosis. — Almost any grade of inflammation involving the nervous 
centers of respiration and circulation in the medulla oblongata and gan- 
glia at the base of the brain, is of serious import. So essential are these 
functions to the maintenance of life that they can not be interrupted, even 
for a few minutes, without fatal results. Consequently all acute attacks 
of inflammation in the nervous centers, controlling these functions, are 
highly dangerous, and a very large proportion of those attacked die in from 
three to seven days. And in many of the cases that do not prove fatal, 
the recovery is not complete, there remaining more or less permanent im- 
pairment of hearing or vision, or of both; and a smaller number in which 
there remains decided weakness of the cervical and dorsal muscles and 
much unsteadiness or impairment of locomotion. 

Treatment. — In cases of ordinary sporadic inflammation of the mem- 
branes and base of the brain, the objects to be accomplished by therapeutic 
management, and the means for accomplishing them, are the same as in 
the treatment of the same grades of meningitis and cerebritis, which were 
fully discussed during the lecture hour of yesterday.* If there is any dif- 
ference, it consists in the more urgent necessity for the early and efficient 

*See pages 334-5 of this volume. 



EPIDEMIC CEREBROSPINAL MENINGITIS. 341 

use of all those means which are capable of lessening the accumulation 
of blood in the vessels and capillaries of the inflamed parts during the first 
stage; in the hope of so modifying the inflammatory process as to prevent, 
or very much diminish, the amount of the exudation which would follow 
in thesccond stage, and which is so liable to prove sufficient to overwhelm 
functions essential to life. If you remember the shortness of the several 
stages of the disease, and the consequent necessity for the most prompt 
and vigilant attention to each case, you will be enabled to so adjust the 
means best adapted to meet the pathological exigencies of each stage 
under the rules I gave you in the lecture of yesterday, as will give your 
patients the best chance of recovery. There is, however, another form or 
grade of inflammation which attacks the base of the brain and its append- 
ages, to which I must now direct your attention. 

Epidemic Cerebro-Spinal Meningitis. — The disease to which I allude 
is seldom met with in isolated or sporadic cases, but usually presents the 
character of an epidemic, sometimes extending rapidly over large districts 
of country, but more frequently limited to neighborhoods or single town- 
ships or counties, to military camps, or even single buildings. Although 
not recognized and described as a distinct disease until the beginning of 
the present century, yet under names indicating some form of typhus, 
pretty accurate descriptions of the disease can be recognized in the histo- 
ries of epidemics occurring in France, Spain and Italy, as early as 1310, 
and at various times during the fifteenth, sixteenth, seventeenth and 
eighteenth centuries, in most of the other European countries. It has 
been called typhus syncopalis, cerebral typhus, petechial typhus, cold 
plague, malignant purpuric fever, febris nigra, spotted fever, apoplectic 
typhus, cerebro-spinal typhus, cerebro-spinal meningitis, epidemic cerebro- 
spinal meningitis, and in the present nomenclature of the R ryal College 
of Physicians, cerebro-spinal fever. Perhaps the first plain description 
of the disease in this country was by Dr. John Bard, who, in 1749,* de- 
scribed the prevalence of a disease in Rhode Island and some other parts 
of New England which was undoubtedly the disease under consideration; 
and Dr. Hugh Williamson gives an interesting account of the prevalence 
of a similar disease in North Carolina in 1792. \ Most writers represent 
it as making its first appearance in the United States in the valley of the 
Connecticut river, a» it passes through portions of Massachusetts, Con- 
necticut and Vermont, in 1806 and 1807. From this time it continued 
to manifest itself in limited districts of New York, Pennsylvania, New 
Jersey, and as far south as Norfolk, in Virginia, until 1812. There was a 
limited prevalence of it in New York, in 1816; in Middletown, Connecti- 
cut, in 1823; and in Trumbull, Ohio, in 1828. From the last date I have 
found no account of the prevalence of the disease until 1840-1, when it 
reappeared in Vermont and Massachusetts, and apparently extended west- 
ward through New York in 1842—3, prevailing severely in some places, 
especially in the western part of the State. It made its appearance in 
different parts of Michigan an 1 Illinois in 1843-4, and during these and 
the four following years, it visited different localities in all the States oc- 
cupying the valley of the Mississippi and its tributaries from the Great 
Lakes to the Gulf of Mexico. Its general habit was to prevail in limited 
districts for one season, disappear, and appear in another series of places 
the next season. It rarely prevailed in the same place two years in suc- 
cession; and equally rare that it spread by continuity of territory. On 

* See Med. and Phil. Reg. Vol. 1. 

t See Med. Repository, 1st series, Vol. II. 



342 EPIDEMIC CEREBROSPINAL MENINGITIS. 

the contrary, it appeared in numerous places almost simultaneously, having 
no special connection of one with another. From 1850 to 1802, I find no 
mention of the prevalence of cerebro-spinal meningitis in any part of our 
country, except one or two limited outbreaks in 1852 and 1858. In the 
winter and spring of 1862-3, it reappeared almost simultaneously in a 
great number of localities, scattered through the Western and Southern 
States, and in several places in the Middle and Eastern States. From the 
last mentioned date to I860, the disease invaded many new places each 
year. It then became less prevalent until 1872, when another marked in- 
crease in its prevalence w<ts observed in different parts of the country. It 
prevailed in this c.ty (Chicago) sufficiently severe to merit the name of an 
epidemic in 1863-4 and in 1872-3, and sporadic cases have occurred in other 
years. 

Causes. — The predisposing causes or circumstances which appear to 
favor the development of epidemic cerebro-spinal meningitis, are: expos- 
ure to cold and damp air, overcrowded and badi y ventilated dwellings, 
poor-houses, prisons, military camps, etc.; to which may be added exces- 
sive fatigue coupled with mental excitement or depression, age and sex. 
In regard to the influence of atmospheric conditions I may state in gen- 
eral terms that the disease has hitherto prevailed chieflv in the northern 
and middle part of the temperate zone, and far more frequently during 
the last half of winter and the early part of spring than at any other sea- 
son of the year. Dr. Joseph A. Gallup, who wrote in 1815, while the facts 
relating to the epidemics in this country from 1806 to 1812 were fresh 
and familiar to him, personally, says: "With few exceptions it has 
broken out in the coldest seasons, and spread most alarmingly at such 
times in the different places it has visited. The months of January and 
February have oftenest given rise to it in point of season. When it rages 
considerably, it continues perhaps to the middle of the month of May, and 
then passes off gradually like other epidemics." * Dr. J. Adams Allen, who 
saw much of the disease as it prevailed epidemically between 1842 and 
1850, says: " According to the writer's (Dr. Allen's) observation, it is 
more likely to occur in winters with a variable temperature — where a few 
days of intense cold are rapidly followed by days of thaw, mud and rain. 
Neither uniformly cold nor warm weather are so likely to engender it. 
But other influences unquestionably co-operate. It does not seem always 
confined to a particular season. "j* In examining the particular season of 
prevalence of a large number of the more severe outbreaks of the disease 
in the epidemic period extending from 1862 to 1872, I find them to have 
commenced in almost all instances during the months of January, Febru- 
ary and March, and to have ended before the middle of June. The dis- 
ease has at no time prevailed as severely in this city (Chicago) as in many 
of the country districts in this and the adjoining States. A few cases oc- 
curred in the month of June, 1863, while during the three preceding 
months cases of erysipelas were more numerous than usual. The only 
epidemic of much note commenced in February, 1872, and continued 
through March and April, during which more than one hundred deaths 
were reported to the health office as resulting from this disease. During 
the same months it prevailed with considerable severity in many of the 
most populous towns in the northern part of Iowa, Illinois, Indiana, the 
southern part of Wisconsin and Michigan, and in the western part of New 
York. From all the foregoing facts it is evident that there is something 

*See " Sketches of Epidemic Diseases in the State of Vermont, from its first settlement to the 
year 1815," etc., etc. By Jo eph A. Gallup. M. D., p. 225. 1815. 
t See paper read to the Illinois State Med cal Society in May, 1S64. Vol. Trans, p 141. 



causes. 343 

more than mere accidental coincidence between the prevalence of the dis- 
ease and the months of winter and Spring* In other words, the usual at- 
raospheric conditions present during the months of January, February, 
March and April, exert a positive, predisposing influence of much im- 
portance in the development of the disease. So far as allusions are made 
to the special meteorological conditions existing at the outbreak of the dis- 
ease in the numerous reports to medical societies and articles in medical 
periodicals, they generally mention the predominance of cold and damp- 
ness with sudden and severe thermometric changes. That the impure air, 
caused by the overcrowding of dwellings, prisons, and military camps, 
favors the occurrence of cerebro-spinal epidemics, is abundantly proved 
by the many special outbreaks of the disease in such places which are on 
record; more especially in connection with military operations both in this 
country and in Europe.* 

There are many facts on record that clearly indicate the important in- 
fluence of excessive fatigue in connection with mental anxiety and fear in 
the fostering of attacks. 

Age. — Although no period of life is exempt from attacks of the disease 
under consideration, yet in all places where it has prevailed among the 
population generally, much the larger number of cases have occurred in 
childhood and youth, and next, in the early part of adult life. Hirsch 
states that of 391 fatal cases 359 were under fifteen years of age. Of forty 
cases that came under my care in the winter and spring of 1872, six were 
between twenty and thirty years of age, ten between five and fifteen years, 
and twenty-four between six months and five years. I think this is a fair 
representation of the ratio of prevalence of the disease at the different 
periods of life, in the epidemics that have occurred in cities and country 
districts throughout this country; but when it makes its appearance at 
military posts, in barracks and prisons, the statistics will show a large ratio 
of prevalence in adult life. This was the case in France during the ten 
years following 1835, when the disease prevailed severely among the 
soldiers in the barracks and camps in different parts of that country. 
Hence Lefevre and other French writers state that the greatest mortality 
occurred between the ages of thirty and forty years. 

Sex. — Writers generally agree in the statement that the disease is more 
prevalent among males than females. In military camps, barracks and 
prisons this would necessarily be the case, as the number of females pres- 
ent in such places is relatively very small. In civil life the difference is 
not great. 

Specific or Exciting Cause. — In addition to the predisposing influences 
I have mentioned, it is claimed by most of the recent writers and observ- 
ers that the disease arises from a specific exciting cause, the nature and ori- 
gin of which, however, is entirely unknown. It is generally conceded that 
the essential cause is not a contagium, communicable from one individual to 
another,but is supposed to be some form of infection, analogous to that which 
causes typhus and other forms of continued fever. The reasoning upon the 

* As a sample of facte touching this subject I copy the following paragraph from an interesting 
letter in the Chic igo Medical Examiner, Vol. V, p. 402, 1834, by Dr. E. Y. Yager, giving an account 
of two epidemic- in Chillicothe. xMissouri. He says : " The epidemic of both 1862 and '64 was pre- 
ceded by ven- cold weather. You will observe that no cases occurred until after the commence- 
ment of the thaw. The wind was generally from the east and very chilly. There was a dense fog 
preceding both epidemics. At the time of its prevalence in 1862 the 'e were quartered near twelve 
hundred soldiers in different parts of the town. They were very much crowded; whole companies 
in houses that were not capable ot ace mimodating more than fifteen. Measles prevailed to an 
alarming extent among soldiers and citizens. There was a very large mortality attending the epi- 
demic of measles, and later in the season pneumonia typhoides was very prevalent. * * * 
The quarters and hospitals were in the worst pjss-ble condition. Following the epidemic of 1864, 
we have erysipelas and pneumonia typhoides." 



344 EPIDEMIC CEREBROSPINAL MENINGITIS. 

subject is not conclusive. It is assumed that the epidemic character of the 
disease proves it to be dependent upon a specific cause. Assuming that 
it depends upon a specific cause is made the reason for classing it with the 
idiopathic general diseases, instead of placing it with the local inflamma- 
tions. It has been suggested by some that while the disease may be a 
general fever caused by some organic poison, such poison, instead of being 
zymotic or imbibed from without, is developed from morbid molecular proc- 
esses in the system.* My own clinical observations, aided by a careful 
study of the more noted epidemics on record, show two facts of much 
etiological interest. First, that there are marked differences in the clinical 
history of the disease under consideration, as it has prevailed in different 
times and places. Second, that all the more noted epidemics have been 
either coincident with or closely allied, both in time and place, to the prev- 
alence of erysipelas or typhoid and typhus fevers, while a much smaller 
number have been coincident with the prevalence of malarious fevers. For 
instance, during its unusual prevalence in France and Spain from 1836 to 
1845, the circumstances under which it originated, and many of the symp- 
toms accompanying the disease, were such as to cause the profession in those 
countries to regard it as a form of typhus. 

So the epidemic that commenced at Medfield, in Massachusetts, in 1806, 
and continued to recur in different places in this country until 1820, was so 
closely connected with the prevalence of typhoid and typhus fevers that it 
was almost universally designated as typhus petechialis, maculated typhus, 
cerebral typhus, etc. And it often happened that while the cerebro- 
spinal fever was prevailing in one neighborhood, in another the local mani- 
festations were developed in the lungs, causing pneumonia typhoides, 
more frequently designated in those days, peripneumonia, and sometimes 
malignant pleurisy; and which often proved as rapidly fatal as when the 
cerebro-spinal axis was involved. Yet during all the periods alluded to, 
both in Europe and in this country, erysipelas was also unusually prev- 
alent, as you may learn by studying the history of that disease. The 
second very extensive epidemic, which prevailed in different places, from 
the New England States west to the Mississippi river, and southward to the 
Galf, between 1841 and 1850, was so completely identified with the coin- 
cident great epidemic of erysipelas, that the history of one necessarily in- 
volved that of the other. In most of the places where they prevailed, the 
cerebro-spinal disease occurred in the winter and spring, and the erysipelas 
in the summer and autumn either preceding or following. And in some 
places they were as intimately intermingled as are cases of intermittent 
and remittent fevers. j- The same close connection between the epidemic 
prevalence of cerebro-spinal meningitis and erysipelas was observed dur- 
ing the severe prevalence of these diseases from 1862 to 1868, in the 
States of Illinois, Wisconsin, Michigan, Indiana, and as far east as the 
western part of New York. During the autumn of 1863 and the winter 
and spring of 1864 both erysipelas and typhoid fever were unusually 
prevalent in this city (Chicago), the former sufficiently so to constitute a 
noted epidemic. During the latter part of the same winter and spring 
many cases of cerebro-spinal disease also occurred, while the two former 
diseases were still prevailing. Perhaps the best account we have of the 
prevalence of these epidemics in the interior of this State, is from Drs. 
Lodge and Samuels who practiced extensively in Williamson county, 

* See Transactions of 111. State Med. Society, Vol. for 1864, p. 141. 

t See short paper on cerebro-spinal meningitis, as it appeared in CI rk county, Illinois, in 1^45-6, 
18">8 ; and 1863-4-5. By F. R. aine, M. D. in the Trans. Ill State Med. ociety for lb06. See also 
Drake on the Principal Diseases of the Interior Valley, etc., second Vol., p. 759. 



EXCITING CAUSES. 345 

where the eerebro-spinal meningitis made its appearance in a very severe 
form in the latter part of the winters of both 18(32 and 1863, and continued 
through the spring months. The erysipelas commenced in the summer of 
18(33 and continued during the following autumn and winter.* 

That severe eerebro-spinal symptoms may occur in connection with 
periodical or malarial fevers, is so we i known that when they occur they 
are generally recognized as indicating one phase of the pernicious inter- 
mittents. I have called your attention, gentlemen, to the intimate rela- 
tions between the prevalence of epidemic eerebro-spinal meningitis and 
the well known acute general febrile diseases, which have been named, for 
the purpose of enabling you to see more clearly the bearing of the ques- 
tion, whether the eerebro-spinal disease is a part of a distinct general 
fever dependent on a specific zymotic cause, or whether it is simply a 
local disease occurring as an important complication in severe epidemics 
of erysipelas, typhoid, typhus, and malarial fevers. In other Avords, shall 
we regard the epidemics of dysentery, pneumonia typhoides, malignant 
pleurisy, and eerebro-spinal meningitis, as so many distinct general 
febrile affections, each dependent on a specific cause, or as local compli- 
cations sometimes based upon the special cause of typhoid and typhus, 
sometimes on that of erysipelas, and at others on that of periodical fevers 
known as malaria? For a few years past the tendency of medical investi- 
gators has been strongly in the direction of increasing the number of 
general acute diseases or fevers, and of assigning a specific cause for each. 
It is under this tendency that acute dysentery, pneumonia, and cerebro- 
spinal meningitis, have already been taken from the list of local inflamma- 
tions and transferred to the class of idiopathic fevers by most of the recent 
writers on practical medicine. I must acknowledge, however, that the 
more I observe these affections at the bedside of the sick, and the more 
minutely I study the histories of the past epidemics, as recorded by those 
who actually witnessed them, the more nearly am I brought to the con- 
clusion that they are simply local affections modified in their phenomena 
and results by whatever general miasmatic or infectious cause may be 
existing at the time, whether it be the idio- miasms that produce typhoid 
and typhus, the infection of erysipelas, or the malaria of the periodical 
fevers. This view affords a much more complete explanation of the noted 
differences in the symptoms and results accompanying these diseases at 
different times and in different localities, and also of the equally diverse 
results of the same methods of treatment in different places and epidemic 
periods. It is also much better calculated to lead the practitioner, when 
he meets these important outbreaks of disease, to observe carefully the 
coincident character and tendencies of the general febrile affections that 
have immediately preceded or are accompanying them, and to base his 
treatment on the actual pathological conditions present, instead of being 
influenced largely by the theoretical idea of the presence and action of 
some one specific organic poison, on which he is led to believe the disease 
before him always depends. 

Symjitoms. — The general group or assemblage of symptoms that accom- 
pany attacks of epidemic eerebro-spinal meningitis, so closely resemble 
those I mentioned as characterizing attacks in sporadic cases, in the first part 
of the present lecture, as to render their full repetition unnecessary. In 
some of the epidemics, the initial symptoms have developed less rapidly; 

*Dr J c . Jewell, speaking of the two diseases as seen by Drs. Lodge and Samuels, says : " The 
two epidemics (spotted fever and erysipelas) were commingled in the practice of these gentlemen, 
occurring at the same time and in the same place, indiicing in them the opinion that the tw form? 
of'diseaoe were connected by some link common to both." See Trans. II.. State Med. Society lor 
18G4, p 25. 



346 EPIDEMIC CEREBROSPINAL MENINGITIS. 

the pulse ha; been softer, more variable and more frequent; an 1 while the 
patients retained their consciousness, they complained of great lassitude 
and weariness, with severe pains in different parts of the body and limbs, 
in addition to that in the head. In other epidemics, one of the noted feat- 
ures was the shortness of the initial stage and the sudden onset of the more 
dangerous symptoms, often so rapidly overwhelming the cerebro-spinal 
functions as to cause a fatal result in a few hours. In still other epidem- 
ics, a large majority of the cases were ushered in by a distinct chill, and 
the fever following exhibited well-marked exacerbations and remissions. 
Such was the character of the epidemics that occurred in the middle and 
lower parts of the Mississippi Valley, from 1842 to 1850, as described by 
Drs. S. Ames, of Montgomery, Alabama; E. D. Fenner, of New Orleans; 
D. Drake, of Cincinnati, and others.* The well-marked though moderate- 
ly severe epidemic of 1872, as it occurred in this city, was faithfully de- 
scribed in a clinical lecture at the time, as follows: 

" The cases have varied much, both in the severity and variety of symp- 
toms, and yet have preserved enough of uniformity to identify them as 
belonging to one group, and dependent on some common pathological 
conditions. For instance, in all the cases the access of the disease was 
sudden or abrupt. They all give evidence, at first, of unusually severe 
pain in the head, with very variable neuralgic pains in distant parts, espe- 
cially in the abdomen, thighs and legs; and, in from one to three days, 
rigidity of the muscles of the neck, with some retraction of the head, and 
general hyperesthesia sufficient to cause even the youngest child to mani- 
fest signs of distress on being touched or moved. In nearly all the cases 
there has been, during the first twelve hours, active vomiting, increased bv 
raising the head to the erect position; and in some, coincident purging. 
These gastric and intestinal symptoms have seldom continued beyond the 
first one or two days. The temperature is generally increased, especially 
in the back of the head; the pulse is frequent and firm; the respirations in- 
creased in frequency, and in most cases, panting, like one excessively fa- 
tigued from severe exercise; face flushed, and expression excited and anx- 
ious at first, but subsequently dull, with dilation of the pupils; urine gen- 
erally scanty and high-colored, but, in some cases, abundant throughout 
the whole course of the disease; tongue covered with a white fur; mouth 
moist; and after the first one or two days, the bowels inclined to consti- 
pation, with the abdomen flaccid, and entirely free from tympanitis. About 
one third of the cases presented some red erythematic spots on the skin, 
between the third and seventh days of the disease. These spots varied 
much in size and number, as well as in shade of color. In the milder cases 
they were bright red, and often so few in number as to attract no attention, 
unless looked for particularly; and in others they were so numerous as to 
create the impression that the case might be one of scarlatina. In the more 
severe cases, the spots were darker in color, larger in size; and in two cases 
they were accompanied with tumefaction, from subcutaneous infiltration, as 
in erysipelas. In a young woman who died on the fifth day after the attack, 
but whom I did not see until the day previous to her death, there were nu- 
merous large, purple, haeinorrhagic spots on the lower extremities, and an 
oblong, elevated, purplish red spot, from one to two inches long, and from 
half to three quarters of an inch in width, on the front part of each ankle 
and the outer face of each wrist. The head was held rigidly and obliquely 
to one side; the eyes were divergent; the pupils dilated, and mind entire - 

* See Diake on the Principal Diseases of the Interior Valley of North America, second vol 
p 758. 



MORBID ANATOMY. 347 

ly unconscious. Tn a m ijority of the cases, however, I failed to discover any 
special eruptions or spots on the surface. Nearly all the cases manifested 
during their progress, paroxysms of excited delirium; and in the children 
some of the first turns of vomiting were followed by protracted turns of wild 
screeching and crying, and sometimes trembling, as if under the influence of 
a terrible fright. Only four cases out of the forty that came under my care 
were accompanied by general convulsions, three of which died and one 
recovered. 1 '* 

Morbid Anatomy. — During the epidemic just described, I had an oppor- 
tunity to make but one post mortem examination. This case was an adult 
male, who died in the Mercy Hospital on the third day after admission, 
and on the seventh day from the commencement of the attack. The 
characteristic symptoms of the disease had all been strongly marked dur- 
ing the progress of the case. The autopsy revealed from ninety to one 
hundred and twenty cubic centimeters (fl. §iii to ?iv) of reddish serum be- 
tween the arachnoid and pia mater, and in the lateral ventricles, with the 
most intense injection or turgescence of the vessels of the pia mater cov- 
ering the base of the brain, medulla oblongata, and upper p irt of the 
spinal cord. The vessels of the brain substance were also fuller than nat- 
ural ; but there had been no exudation of lymph or plastic material ; and 
there were no other morbid appearances apparent to the unaided eye. My 
colleague, Dr. J. S. Jewell, in his paper on the cerebro-spinal meningitis, 
read to the Illinois State Medical Sjciety in 1806, collected and examined 
accounts of about two hundred autopsies. From these examinations, and 
from many others since, it appears that the most constant of all the post 
mortem phenomena are congestion with more or less inflammation in the 
pia mater and surface of the base of the brain, medulla oblongata, and 
upper part of the spinal cord. In a large majority of the cases there is 
also some serous, sero-purulent, or purulent exudation or effusion upon the 
surface of the pia mater, between it and the brain structure, and in the 
lateral ventricles. The amount of serum varies from one or two cubic 
centimeters to as many hundred, (fl. 3ii to 5vi) ; its color is usually a little 
turbid, sometimes reddish from intermixture of blood corpuscles, and at 
other times more purulent, and of a creamy consistence. In only a small 
number of cases has there been any true plastic exudation, either in the 
serum or upon the surface of the membranes. The vessels of the brain 
structure were often seen congested, and sometimes, though rarely, the 
structure itself softened. 

Microscopic examination shows migrating white corpuscles in the con- 
gested parts of the brain, medulla, and spinal cord ; and abundance of pus 
corpuscles in the effused serum, with some fibrin, and occasionally red 
corpuscles. In a few cases, the effused fluid has appeared gelatinous from 
the amount of mucin it contained. As a rule, the more speedily fatal an 
attack proved, the less were the anatomical changes recognizable after 
death. The same rule, however, is applicable to all severe epidemic dis- 
eases. No changes specially characteristic of this disease have been found 
in other parts of the body. In the epidemics which prevailed in this 
country from 1806 to 1820, and in France from 1835 to 1845, many of the 
post mortems revealed important changes in the thoracic organs ; such as 
severe engorgement of the lungs with dark blood in some ; pleurisy, and 
pleuro-pneumonia in others ; serous and sometimes purulent deposits in 
the cavities of the pleura and pericardium in a few ; while in others there 
was only hypostatic congestion or no change of any kind. Many of the 

* Pee Clinical Lectures on Important Dis3as33. By N.*J. Ea/is, M. D. etc, pp. 243-6-7, 2d Ed. 
Ifc74. 



3i8 EPIDEMIC CEREBRO-SPINAL MENINGITIS. 

same examinations showed hyperaemia and slight tumefaction of the glands 
of Peyer and Brunner in the ilium, and in a very few cases, some degree 
of ulceration. 

The autopsies made during the epidemics prevailing in this country 
from 1841 to 1850, and from 1862 to 1870, revealed much less pathological 
changes in the viscera of the chest, and decidediy more in the kidneys, 
small intestines, and mesenteric glands. The most noted change in the 
blood itself was an increase in the relative proportion, both of fibrin and red 
corpuscles, with an unusual tendency to form coagula in the cavities of 
the heart and larger vessels. 

Special Pathology. — Whether you are to regard the disease under con- 
sideration as a general cerebro-spinal fever arising from a special zymotic 
cause, or a local inflammation engrafted, in some perio.ls, upon a general 
typhous epidemic; in others, upon an erysipelatous epidemic; and in still 
others, upon some nod fication of the malarial poison, in either event, both 
the symptoms during life and the pathological changes revealed by post mor- 
tem examinations show that the principal seat of d sense and source of dan- 
ger to the patient, is in that part of the nervous centers composing the base 
of the brain, medulla oblongata, and upper part of the spinal cord with 
the immediately investing membrane. They also show that the disease 
affecting the parts named, is really an asthenic grade of inflammation, in 
which trie elementary properties of the parts are so altered as to impair 
the tonicity or contractility of the smaller vessels and the natural molecu- 
lar movements, thereby inducing rapid accumulation of blood, aplastic 
exudations, and the early suspension of functions essential to the contin- 
uance of life. In cases of the highest grade of severity, the properties of 
the tissues involved are so profoundly altered, as to arrest the natural 
molecular movements entirely and cause death in a few hours, leaving but 
little traces of congestion or other inflammatory appearances visible to the 
unassisted eye. 

Diagnosis. — The diseases with which epidemic cerebro-spinai meningitis 
is most liable to be confounded are typhus fever, malignant scarlet fever, 
pernicious intermittents, and ordinary sporadic inflammation of the brain. 
From the first, it is to be distinguished by the suddenness of the attack, 
usually accompanied by vomiting, and the early occurrence of rigidity of 
the cervical muscles and retraction of the head. Attacks of the second 
and third may be equally sudden, and are also accompanied by vomiting 
in a large proportion of cases; but they present neither the stiffness of 
the neck nor the retraction of the head, which so uniformly characterizes the 
cerebro-spinal disease; unless the latter actually exists as a complication, 
which sometimes happens. You will also derive some aid from the pres- 
ence or absence of a general prevalence of either scarlatina or periodical 
fevers. To differentiate between the epidemic and the ordinary sporadic 
cases of cerebro-spinal inflammation, is more difficult. If you keep in mind 
the facts that the former usually occur suddenly without any known 
exciting cause; that several cases occur nearly simultaneously in the same 
community, or follow each other in quick succession, that the pulse is 
softer and more variable in frequency, with less rapid rise of temperature, 
and earlier retraction of the head; while the latter are generally preceded 
by known exciting causes; occur singly; develop early a higher temper- 
ature and fuller pulse, and more uniformly contracted pupils, and are not 
marked by any purple or petechial spots on the cutaneous surface in the 
middle and latter stages of their progress, you will be able to keep the 
line of distinction with reasonable certainty. 

Prognosis. — The disease under consideration is always attended by a 



PROGNOSIS. 349 

hinrh ratio of mortality. Most of the foreign writers make the ratio vary 
from 50 to !"> percent. In this country there have been very great differ- 
ences in the death rate, in different epidemic periods and in different 
places during the same period. From Dr. Gallup's detailed account of 
the epidemics in Vermont from 1807 to 1815, I find the number of deaths 
in proportion to the whole number of cases given, in only a few instances. 

During its prevalence in the town of Reading in the winter of 1811, of 
55 eases only 8 died. In the same town in the winter of 1812, of 60 
eases 9 died; while in the neighboring town of Plymouth during the same 
season, of 30 cases 4 died. These aggregate 145 cases and 21 deaths, or 1 
in G.90. During the years 1812 and 1813 the disease prevailed severely in 
the environs of Philadelphia and in neighboring towns, an account of 
which may be found in the Medical and Philosophical Register, vol. i ; i. 
During that epidemic, the mortality is stated by Dr. Philip S. Wales, U. 
S. N., as one in four or five cases. The epidemic that occurred during ihe 
great epidemic period of erysipelas, from 1841 to 1850, produced a larger 
ratio of mortality than those occurring during the first two decades of the 
present century, and has been equaled since only by the prevalence of 
the disease in the States occupying the middle and lower parts of the 
Mississippi Valley, from 1862 to 1868, commencing while extensive mili- 
tary operations were going on in these States. 

Dr. S. Ames, of Montgomery, Alabama, whose Monograph, published in 
1848, contained, perhaps, the best account of the disease as it prevailed 
in the Southwestern States during the period between 1841 and 1850,'is 
very generally quoted by more recent writers as making the ratio of 
mortality 60 per cent. This is manifestly incorrect. Dr. Ames grades 
the whole number of cases into three classes, the mild, the grave, and the 
malignant, and expressly states that of the lasr named class 60 percent died. 
He further states that but few of those cases classed as grave cases died, 
and none of those ranked as mild. He further represents the malignant 
class as embracing a little more than one half of the whole number of 
cases that occurred. It is evident, therefore, that in the epidemic 
described by Dr. Ames the ratio of deaths to the whole number of cases 
was not far from 33 per cent. And this is probably very nearly the cor- 
rect ratio of deaths from the disease throughout the whole of that epidemic 
period. For while in some isolated or very limited outbreaks of the 
disease nearly all the cases died, in the great majority of places where the 
whole number of cases from the beginning to the end of the epidemic 
can be ascertained with an approximation to accuracy, the death rate 
ranged between 1 in 1.5 and 1 in 7, or a general average of 1 in 3.* 

Of the forty cases that came under my own care during the months of 
February, March and April, 1872, thirty-two recovered and eight died. 
Of the eight fatal cases, one died in about twenty hours from the com- 
mencement of the attack, two in four days, one in five, one in six, one in 
seven, one in twelve, and one in twenty-eight days. 

It has been very generally observed, that the attacks which occur at 
the beginning of an epidemic, in any given locality, are more malignant 
and cause a much larger ratio of deaths than those which occur after the 
epidemic has passed its crisis and the number of new cases is diminishing. 
The same rule, however, applies to all severe epidemic diseases. 

Having spent more time than I had intended in the consideration of 
the history, causes, and relations of the disease, I must defer the discussion 
of its treatment until the next lecture hour. 

* See Report on Practical Medicine and Epidemic Diseases, by D. Francis Condie, M. D., in the 
Trans. Amer. Med. Association. Vol. ii. pp. 156-7, 184'J. 



350 EPIDEMIC CEREBROSPINAL MENINGITIS. 



LECTURE XXXVII. 

Epidemic Ocrebro-Spinal Meningitis Continued. — Tts Treatment and Sequelae.— Spinal Men- 
ingitis and Myelitis; Their Causes, Symptoms, Morbid Anatomy. Diagnosis and Treatment. 

(1 ENTLEMEN: In regard to the treatment of epidemic cerebro-spinal 
J meningitis, or spotted fever, very much might be said of historic 
interest, strikingly illustrating the tendency of the human mind to resort 
to heroic and even reckless medication, in combating diseases of sudden 
development and fatal tendency. Bleeding, general and local; vomiting 
and purging; calomel, opium, quinine, alcoholic anaesthetics, and blister- 
ing, have all been resorted to at different times and places, and used with 
an unsparing hand. Each has been commended by some and condemned 
as worse than useless by others. In the epidemics occurring during the 
first two decades of the present century, venesection was practiced very 
freely by a large proportion of the practitioners in the New England 
States. For instance, vie are told by Dr. Gallup, that seventy-three cases 
of spotted fever occurring in the towns of Greensborough and Hardwick, 
in the spring of 1811, were treated by Dr. Huntington without a single 
fatal case. "He bled from one to Jive times, sweated, gave also val. 
tincture of gum guaiac, ether , etc."* 

In another place, Dr. Littlefield, who treated many cases during an 
epidemic in the winter and spring of 1813, is represented as bleeding the 
patients from two to four times, from twelve to twenty-four ounces each 
time, with very great success. f 

Dr. Gallup himself treated eighty-one well marked cases, embracing 
all ages and both sexes, during the epidemic of 1811, without any opium, 
but with from one to four bleedings, in more than half of the cases, and 
with the loss of only one of the whole number. Others used emetics, 
cathartics and calomel very freely during the same epidemic, but with 
very little evidence of good results. Of all the remedies used, how.-ver, 
none were used more lavishly than opium and the alcoholic liquors. 
Throughout the Connecticut Valley, where the doctrines of Drs. Miner 
and Tully in regard to the use of opium in fevers, exerted much influence, 
these remedies were given in cases of spotted fever in doses and quantities 
so large as to suggest doubts concerning the sanity of those who directed 
their administration. Dr. Miner says that, " Opium was the most important 
remedy in the severe form of this disease. * * * A few cases imperi- 
ously required half an ounce of the tincture in an hour, or half a drachm 
in substance, in the course of twelve hours, * * * and even some 
cases required a drachm in the s^ine time. All these patients recovered" 
Dr. B. II. Catlin, of Meriden, Connecticut, cites cases in which from three 
to five grams (gr. xlv to lxxv) of opium were given each day for 
two or three days in succession. Concerning a young lady of fifteen or 
sixteen years of age, to whom he was called on account of the sickness of 
her attending physician, he says: "She w T as taking a large pill of opium, 
between two and three grains, every four hours; a large dose of laudanum, 
nearly a teaspoonful, every four hours; infusion cort. cinchona, brandy, 
and pepper tea, all the stomach would bear." Dr. Catlin does not say, 
however, that "all these patients recovered." On the contrary, he admits 
that many of them died; and plainly suggests that many cases were 

* ?ee Gallup on Epidemics, p. 67, 
t Ibid, p. 73. 



TREATMENT. 351 

altogether fictitious, the cerebral symptoms and sinking being produced 
by the remedies instead of the disease.* 

Equal extravagances have characterized the treatment of many cases 
during- the later epidemics, as in those of the first two decades of the pres- 
ent century. For example, Dr. J. Adams Allen, in the paper read by him 
to the Illinois State Medical Society, in 18G4, says: "I have known fifty 
grains of morphine given, within a dozen hours, to a boy of fifteen, to 
relieve him from the terrible pain and suffering, with no avail, save that 
death followed." And he adds: " Incalculable quantities of brandy and 
quinine, of capsicum and carbonate of ammonium, have been poured into 
the stomai'hs of the comatose.'" f 

I have made these brief allusions to what may be called the extrava- 
gances of the past, for the purpose of giving you some idea of the variety 
of treatment to which the disease has been subjected, and still more to 
show the extent to which the human system can be rendered insensible 
to the action of the most powerful drugs by the presence of certain con- 
ditions of disease. 

You all know that the human system in its healthy or normal state of 
susceptibility and molecular movements would be dangerously if not fatally 
narcotized by less than one third of the five grams (gr. Ixxv) of opium 
which were given two and three days in succession, and in some instances 
without fatal effects. Similar want of susceptibility to the action of 
opiates and alcoholics, is also seen in cases of tetanus, delirium tremens, 
and many of the more malignant cases of general fever. But such toler- 
ance of any particular drug, neither proves that the drug is indicated, 
nor its administration in unusual quantity free from danger. On the con- 
trary, it rather points to the necessity of using something more directly 
calculated to arouse the general susceptibility and vasomotor activity, 
and thereby avert the danger of entire suspension of molecular move- 
ments in the nervous centers as occurs in the more rapidly fatal cases on 
the one hand, and on the other, establish a better response to the impres- 
sion of remedial agents of all kinds. The danger of administering enor- 
mous or unusual quantities of any narcotic or anaesthetic during a stage of 
extreme pain or temporary suspension of susceptibility from a morbid con- 
dition, consists in the fact that a sufficient quantity of the drug may remain 
in the system after the pain ceases or the susceptibility to its action returns, 
to produce dangerous toxic effects. When it was customary to treat 
tetanus and delirium tremens with very large and frequently repeated 
doses of opium, not a few of the patients died from excessive narcotism 
after the tetanic spasms and delirium had ceased. Even during the last 
few years no less than three cases of delirium tremens have come under 
my own observation in which the attending physician after giving large 
and frequent doses of bromides, chloral hydrate and morphine, finally in- 
duced sleep, but it was a sleep from which they never awoke. In one of 
the cases the last dose was a hypodermic inj jet on of morphine. 

The leading indication to be fulfilled, or object to be accomplished, by 
treatment in the special form of disease under consideration, is to obtain 
an early abatement of the morbid action and vascular fullness in the cere- 
brospinal nervous centers, thereby relieving the pain, relaxing the mus- 
cular rigidity, and preventing fatal paralysis. From what I stated in the 
preceding lecture concerning the close association of the disease with ery- 
sipelas on the one hand and with tvphus on the other, you will infer that 

* See Report on the Clima ology and Epidemic Diseases of Connecticut. By B. H. Catlin, M. D. 
in the Trans. Amer. Med. Association, Vol 16, pp. 486-188, 490. 
t tee Trans. Ill State Med >ociety for 1864. 



352 EPIDEMIC CEREBROSPINAL MENINGITIS. 

the nature of the inflammatory process or morbid action in the cerebro- 
spinal textures will either partake of the specific qualities of the former or 
of the asthenic grade of the latter. Consequently direct depletion by 
bleeding could be beneficial only in the beginning of such exceptional 
cases as presented unusual cardiac force and arterial tension. And the 
same rule would apply to the use of such cardiac sedatives as the veratrum 
viride and aconite. In the great majority of cases we must rely upon 
those agents which are known to be capable of so acting upon the vaso- 
motor nerves as to induce contraction of the cerebro-spinal vessels, thereby 
lessening the fullness of blood and checking the tendency to exudation and 
effusion. Perhaps the most reliable agents we possess for that purpose are 
the ergot, physostigma and belladonna. In the epidemic of 1872, in this 
city, I treated the first three case 4 that came under my care with local 
bleeding by leeches, followed by blisters; the internal use of bromides, 
iodides, and mild laxatives, aided by ice bags to the head and neck, but 
with no marked benefit. The first case terminated fatally, and the n^xt 
two w T ere doing badly, when I substituted for the remedial agents just 
mentioned, the administration of the tincture of physostigma with decided 
benefit. From that time to the end of the epidemic I gave the physostigma 
and ergot combined, to nearly all of the cases that came under my care, as 
the leading remedies during the active stage of the disease. When called 
soon after the commencement of the attack, I usually directed a sack or 
pillow of pounded ice to the occiput; or if this could not be obtained, 
cloths wet in cold water and frequently renewed; and the following pre- 
scription to be given internally: 

Ij6 Tinctune Physostigmatis 45.0 c. c. §iss 

Extracti Ergotae Fluidi ?5.0 c. c. §iiss 

Mix. Give to an adult four cubic centimeters (fl. 3i) every two or three 
hours, according to the urgency of the symptoms. 

If chere was gastric irritability with more or less vomiting, I directed 
four cubic centimeters (fl. 3i) of the following formula to be given half 
way between the doses of the physostigma and ergot: 



Acidi Carbolici 


0.40 grams 


gr. vi 


Glycerinae 


15.00 c. c. 


3iv 


Tincturas Gelsemini 


15.00 c. c. 


3iv 


Aquae 


90.00 c. c. 


Jiii 



Mix. 

If there had been no movement of the bowels during the preceding 
twenty-four hours or more, I gave a single powder containing three deci- 
grams (gr. v) each of calomel and bicarbonate of sodium, and if it did 
not move the bowels in four hours, aided it by a moderate dose of the 
Rochelle salts or citrate of magnesium. If after the first one or two days the 
disposition to vomit ceased, which was usually the case, the carbolic acid 
and gelseminum mixture was omitted. Whenever the rigidity of the 
muscles of the neck and the pain in the head had abated, the interval be- 
tween the doses of physostigma and ergot were lengthened to three, four, 
six and finally to eight hours. If as convalescence approached, the patient 
was restless, mentally wandering, or sleepless during the night, I found a 
single, fair dose of the compound powder of opium and ipecacuanha 



TREATMENT. 353 

with pulverized gum camphor, given at bed-time each night to procure 
good rest and to materially hasten the establishment of convalescence. 
As soon as the latter was fairly established, the ergot and physostigma 
were omitted; for when continued longer, they appeared to increase the 
tendency to that cerebral anaemia and general emaciation which in some 
instances greatly protracted the period of convalescence. In a few cases 
after t lie crisis or active stage of the disease had passed, an exacerbation 
of fever would occur about the same time each day. These were quite 
uniformly interrupted by two or three moderate doses of sulphate of qui- 
nia each day. After the first day the patients were carefully sustained 
by simple nourishment, consisting principally of milk and beef tea, given 
in small doses, regularly, at short intervals. By the foregoing manage- 
ment, carefully adjusting the doses to the age of the patient and the ac- 
tivity of the disease, of the whole number that came under my care one out 
of six died.* You must remember, however, that every epidemic of 
this disease needs to be studied carefully, both in relation to the special 
character of the symptoms it presents, and its relation to the coincident 
prevalence of other diseases. And the treatment must be varied to suit 
the special character of each epidemic. If the disease should manifest 
itself at a time when coincident diseases were manifesting an active in- 
flammatory tendency, as was evidently the case in Vermont from 1811 to 
1813, I should not hesitate to take one free bleeding from the arm at the 
beginning, following it promptly by arterial sedatives and a mercurial ca- 
thartic, after which the ergot would be applicable, and most of the other 
measures I have indicated. If it should come in the midst of a general 
epidemic of erysipelas, as was the case from 1841 to 1850, I would place 
less reliance on cold applications to the head and neck and the use of ergot 
and physostigma, and more on early douches of warm water to the occiput, 
followed by blisters and the internal use of hyposulphites cf sodium and 
belladonna, tincture of chloride of iron, tincture of cantharides, and due 
attention to the action of the kidneys and bowels. And if there should be 
present also a strong malarious influence, causing most of the attacks to be 
ushered in by a decided chill and imparting to the subsequent fever some 
degree of remittent character as was the case in many places in the middle 
and lower part of the Mississippi valley, both in the epidemics of 1841-50, and 
1862-8, I should expect to obtain much benefit frsm the timely use of fair 
anti-periodic doses of sulphate of quinia. In regard to cpium, which many 
writers place at the head of the list of remedial agents for the treatment 
of this disease, I can only say that its use during the active stage of the 
disease in such cases as have come under my observation, has proved posi- 
tively injurious. But in the stage of decline, to allay restlessness and 
procure sleep at night, and to control neuralgic pains during convales- 
cence, it has proved very beneficial, especially when given in connection 
with camphor or quinine. If given in the early stage of the disease at all, 
it should be in moderately full doses just after a general or local bleeding 
sufficient to temporarily relieve the vascular fullness. With the systolic 
force of the heart and the tension of the vessels abated by the loss of 
blood, or less certainly by the use of cardiac sedatives, the efficient influ- 
ence of opium in overcoming the morbid excitability of the structures, 
would have a strong tendency to prevent the renewal of the vascular full- 
ness, and help to cut short the inflammatory process. If whatever reme- 
dies are used in the first stage of the disease should fail to arrest, or so far 
modify the morbid conditions as to prevent exudation and effusion, and 

* For further details see volume of Clinical Lectures on "Various Important Diseases, edited by 
Frank H. l avis, M. L>.. 2d ed., pp. 241-50, 1874. 

23 



354 EPIDEMIC CEREBROSPINAL MENINGITIS. 

stupor, coma and paralysis ensue, there is little reason to hope for a favora- 
ble result from further treatment. And yet it may be well to apply blis- 
ters and mercurial inunction, and give internally full doses of iodide of 
potassium, either by the mouth or in nutritive enemas when deglutition is 
difficult or suspended, for the purpose of preventing further exudation and 
promoting the absorption of what may already exist; as recoveries have 
occasionally taken place from conditions apparently hopeless. In all 
cases in which convalescence follows attacks of this disease, great care 
should be taken to have the patient avoid all active mental or physical ex- 
ercise or excitement until strength and nutrition are well restored. Much 
rest in a recumbent position, good air, a moderate variety of plain, easily 
digested food, and the avoidance of strong tea and coffee, and of all kinds 
of fermented or distilled drinks, will insure the most rapid and complete 
recovery with the least danger of relapses. If any medicine is used during 
convalescence, such as will aid in re-establishing healthy nutrition will be 
the most useful. For this purpose you may direct the patient to take four 
cubic centimeters (fl. 3i) of the syrup of lacto-phosphate of lime, or of 
the compound syrup of the hypophosphites, just after each meal, and the 
same quantity of the fluid extract of the humulus lupulus at bed-time. The 
latter will allay nervous restlessness and promote natural sleep. 

Sequelce. — The important pathological conditions liable to follow as "a 
result of the epidemic cerebro-spinal meningitis, are, a spanasmic or im- 
poverished condition of the blood with general impairment of nutrition; 
frequent and severe neuralgic pains, often changing their location from 
one set of nerves to another, with difficulty of maintaining the erect 
position without inducing vertigo and muscular trembling, and more or 
less permanent impairment of vision, and, in some cases, of the mental 
faculties also. The first condition I have mentioned is best remedied by 
;a continuance of the same management that I have just mentioned as 
.proper during the stage of convalescence. The cases included in the second 
condition or sequel, differ from the first in the fact that they are still 
.affected with a certain degree of irritation or morbid sensitiveness in the 
cerebro-spinal centers in addition to the general anaemia. And it is the 
-continuance of this central irritation that causes the tormenting neuralgic 
pains without the least regularity as to time or place; although in a 
majority of cases they are most frequent and severe in the heads of the 
gastrocnemii muscles, in the abdomen, and in the head. In nearly all the 
cases of this kind that came under my observation, I gave a mixture of 
two parts of camphorated tincture of opium with one part of the tincture 
of physostigma each morning, noon, and tea time, and a moderately full 
dose of the compound powder of opium and ipecacuanha with quinine at 
bed-time, with early and permanent relief. Some of this class of cases 
were troubled less with neuralgia, and while at rest, appeared quite well, 
but every attempt to maintain the erect position or walk, would cause 
marked dilation of the pupils, vertigo, and trembling of the voluntary 
muscles to such an extent as to threaten convulsions unless the recumbent 
position was immediately resumed. One of the most prominent cases of 
this kind was that of an adult male, naturally strong and healthy, to whom 
I was called in consultation nine weeks after he had been attacked with 
the epidemic cerebro-spinal disease in 1872. He passed through the active 
stage of the disease and reached apparent convalescence at the end of the 
second week. The only symptoms that remained were a moderate enlarge- 
ment of the pupils, a pallid or anaemic hue of the surface, slowness of the 
pulse when resting in the recumbent position, which became quick and vari- 
able when the patient attempted any muscular exertion, and wide dilation of 



SEQUEL M. 355 

both pupils, with vertigo and universal muscular trembling to such an 
extent as to render him incapable of remaining one minute in the erect 
position. His temperature was natural, appetite fair, renal secretion good, 
and mental faculties unimpaired. His attending physician, regarding the 
symptoms I have mentioned as the result of serous effusion into the 
lateral ventricles, had kept him on a spare diet and from three to six gram 
doses (gr. v to x) of iodide of potassium up to the time of my visit, but 
with no improvement in the condition of the patient.. 

The natural expression of countenance, the ready use of the mental 
faculties, the ability to command the movements of any of the voluntary 
muscles when at rest in the recumbent position, appeared to me incom- 
patible with the existence of effusion either into the ventricles or upon the 
surface of the brain; while the dilation of the pupils, the vertigo, and the 
muscular agitation produced by an erect position clearly indicated cere- 
bral amaemia and defective nutrition. I consequently persuaded his phy- 
sician to omit the further use of the iodides, and substitute in their place 
fair doses of the compound syrup of the hypophosphites; to allow a more 
liberal diet of plain food, and avoid, as far as possible, all muscular exertion 
or change from the recumbent position. Under this simple method of 
treatment he soon began to show signs of improvement, and in about 
three months, fully recovered, and subsequently resumed his occupation 
as an engineer. 

Those cases of decided impairment of the heanng and vision, with 
partial paralysis and imperfect use of the mental faculties, which are occa- 
sionally met with as the sequel of severe attacks of epidemic cerebro- 
spinal disease, are but little influenced by any treatment that has been 
devised. In these cases, the structural changes in the inflamed portions 
of the brain have become permanent; and though the patient may live for 
months, or even years, very few ever gain the norma.l condition of their 
cerebro-spinal functions. 

The next subject to which I must direct your attention is 

SPINAL MENINGITIS. 

By spinal meningitis, I mean inflammation of the membranes and surface 
of any part of the spinal cord from its junction with the medulla oblongata 
to its caudal extremity. Simple idiopathic inflammation of this part of the 
central portion of the nervous system, is not of frequent occurrence, if we 
exclude from our consideration those cases that arise from the causes of 
constitutional syphilis and rheumatism, both of which have been sufficiently 
discussed in lectures thirty and thirty-one of the present course. The 
outer membran®, or dura-mater, of the cord is liable to the same forms of 
disease as that which envelops the brain, and which I have described 
under the names of pachymeningitis externa and interna. But they arise 
from the same causes, and are so generally associated with the correspond- 
ing pathological conditions within the cranium that a separate description 
is not necessary. Inflammation of the arachnoid and pia mater may be met 
with in all grades of activity from the most acute to the most chronic form 
of the inflammatory process. 

Etiology. — The most common causes of simple spinal meningitis are 
mechanical injuries, such as concussions, contusions, twisting, or wrench- 
ing, etc., and sudden exposures to wet and cold. The first class of causes 
are most liable to induce a subacute grade of inflammation, limited to some 
one section of the coi*d, while the sudden exposures to wet and cold more 
generally induce acute attacks, embracing the whole length of t' e cord. 



356 SPINAL MENINGITIS 

Symptoms. — The commencement of acute inflammation of the pia ma- 
ter and surface of the cord is usually characterized by chilliness or rigors, 
with paleness of the features, and severe pain in the back. The first two 
symptoms continue only from one to three quarters of an hour, and give 
place to some flush of the face, moderate elevation of temperature, greater 
frequency and fullness of the pulse, respiration shorter and more frequent, 
and very severe pain in the affected part of the spine, much increased by 
motion. There is also generally hyperesthesia or increased sensibility of 
the cutaneous surface, with acute pains following the course of the spinal 
nerves both around the body and in the extremities, and often accompa- 
nied by muscular contractions causing a sense of constriction like the im- 
pression of a hoop or band around the body. The tongue becomes cov- 
ered with a whitish coat, the urine scanty, high colored, and more acid 
than natural, the patient very restless yet tortured with great increase of 
pain by every attempt to move or bend the spine, and frequent cramps or 
rigid contraction of some of the muscles. When the inflammation is acute 
and extending the whole length of the spine, or even the length of the cer- 
vical and dorsal portions of it, the pain in the spine and along the course 
of the intei costal and other thoracic nerves with the accompanying muscular 
contractions or rigidity, so interferes with respiration as to cause intense 
suffering and anxiety, and sometimes causes sudden death by apncea, in 
the early stage of the disease. If the patient escapes this danger, in from 
three to seven days, according to the grade of activity, the symptoms be- 
gin to change, the temperature diminishes, the pulse becomes smaller 
and often variable in frequency; the pains and hyperaesthesia diminish, 
with corresponding abatement of muscular cramps and rigidity; and in 
one or two days more, the hyperaesthesia and pain have given place to anaes- 
thesia or loss of sensibility, and the previously contracted muscles become 
entirely relaxed. In other words, paralysis of both sensation and motion 
has followed the stage of irritation. These effects will be manifested only 
in such parts as are supplied with nerves from the inflamed portion 
of the spinal cord and the parts below. If the upper part of the cord is 
involved, the paralysis may include the muscles of the chest to such an 
extent as to cause a fatal result from the suspension of respiratory move- 
ments. If the disease is limited to the lower half of the cord, the paraly- 
sis may affect only the lower extremities, or it may extend high enough to 
include the hips and viscera of the pelvis, and render the patient incapable 
of controlling the urine or faeces. In most cases of spinal meningitis both 
lateral halves of the cord are involved, causing all the symptoms to be bi- 
lateral; that is, involving corresponding parts on both sides of the body. 
In some cases, however, the disease is not equally severe on both sides. 
In most cases, also, as you will infer from the symptoms I have detailed, 
the disease involves the nerves from both anterior and posterior columns 
of the cord, thereby disturbing the functions of motion and sensation, at 
the same time. In many cases, however, the disease does not progress 
with equal rapidity in both columns; causing, in some, the continuance of 
sensibility and even hyperaesthesia after the loss of motion in the same 
parts is complete, and in others the order of progress will be reversed, 
showing complete loss of sensibility, while the muscles of the part remain 
rigidly contracted. When the lower part of the body and limbs are fully 
paralyzed, with dribbling of urine and involuntary discharge of faeces, 
there is much danger of the formation of large and deep bed sores over 
the sacrum and trochanters, with progressive loss of flesh and strength 
until death results from asthenia. If, as happens in a certain proportion 
of the cases, the attack of inflammation is less severe, the resulting paral- 



MORBID ANATOMY. 357 

ysis of either sensation or motion will be only partial, and by proper man- 
agement the patient will slowly recover. 

Morbid Anatomy. — The pathological and anatomical changes which 
take place in the different grades of spinal meningitis are the same as in 
the corresponding grades and stages of cerebral meningitis, already 
described. During the first stage, corresponding with the period of severe 
pain, hyperesthesia, muscular contractions, and general fever, the pia 
mater and surface of the cord are intensely red from the congestion or 
accumulation of blood in the vessels and capillaries of the inflamed parts. 
This, in a time varying with the intensity of the vascular engorgement, is 
followed by exudations into the membrane and portions of the surface of 
the nerve substance, and eifusions of serum, between the arachnoid and pia 
mater, in some cases colored with blood corpuscles, and in others rendered 
turbid from the intermixture of pus. It is the pressure of these accumu- 
lating products of the inflammation upon the substance of the cord, that 
causes the transition of symptoms from those of active irritation and excite- 
ment, to those of debility, anaesthesia and muscular paralysis, which mark 
the second stage of the disease. If the case has terminated fatally soon 
after the second, or stage of paralysis has supervened, there will usually 
be no other morbid appearances in the interior of the cord than slight 
congestion of the vessels. But if life has been protracted through a long 
period of time after paralyses from the continued pressure of the effused fluid 
and other inflammatory products on the cord, much atrophy or wasting of 
the nerve structure may be found to have taken place in addition to other 
changes. In some cases the serous effusion is less and there is plastic 
material in its place, both on the surface of the pia mater and between it 
and the substance of the cord, causing sometimes adhesions between the 
surfaces of the arachnoid and pia mater. 

Diagnosis. — The chief diagnostic symptoms of spinal meningitis are, 
severe pain in some part or the whole of the spinal column, greatly in- 
creased by bending or moving the part, hyperaesthesia of the whole sur- 
face, or of such parts as receive sentient nerves from the part of the spinal 
cord affected; more or less contractions of the muscles supplied with 
motor nerves from the same source; more or less general fever as indicated 
by increased heat and frequency of pulse; and when the inflammation 
involves the middle and upper sections of the cord, the characteristic 
sense of constriction, as of a band around some part of the chest or abdo- 
men. There is very generally tenderness to pressure on each side of the 
spinal column, but not direcdy on the spinous processes. Neuralgic and 
hysterical affections are neither characterized by general fever nor the 
persistent pains and muscular contractions of the first stage of spinal 
meningitis. From acute and subacute rheumatic inflammation it is dis- 
tinguished by its fixed or non-migratory character and by its early tend- 
ency to develop more or less paralysis of sensation or motion, or of both. 

Prognosis. — Acute inflammation, occupying the membranes and a large 
part of the surface of the cord, is a dangerous form of disease, proving 
fatal in a large percentage of cases. When it is limited to a small part of 
the cord, and especially to the low T er third, the proportion of recoveries is 
much larger, simply because it does not involve paralysis of parts whose 
function is essential to the continuance of life. The longer any part of 
the cord remains under pressure from the exudation and other inflam- 
matory products, the less will be the prospect of ultimate recovery. The 
earlier any given case can be brought under judicious treatment, the better 
will be the prospect of success. 

Treatment. — The body should be kept in a recumbent position, as free 



358 SPINAL MENINGITIS. 

from motion as possible and upon one side instead of the back. In the 
first stage of all acute and subacute cases, free local depletion by leeches 
or cups, followed by frequent douches or sponging with hot water along 
the spine for twenty-four hours, and the subsequent application of blisters, 
or other means of efficient counter-irritation, will constitute the best 
external measures of treatment. Internally, you can give to an adult 
from three to six decigrams (gr. v to x) each of calomel and bicarbonate 
of sodium, and follow it in three hours by sufficient sulphate of magnesium, 
or other saline laxative, to secure a free movement of the bowels. As soon 
as this is accomplished, you can give one gram (gr. xv) of the salicylate of 
sodium in solution, every three or four hours, and a powder of calomel, six 
centigrams (gr. i), and the compound powder of opium and ipecacuanha 
four decigrams (gr. vi), between the doses of the salicylate. If the pulse 
is hard and quick and the temperature high, from three to five minims of 
the tincture of veratrum viride may be added to each dose of the solution 
of salicylate of sodium until the acuteness of the symptoms abate. If 
under the use of these remedies the temperature falls, the pulse becomes 
slower and more easily compressed, the pains in the back and general 
hyperesthesia diminish, and especially if muscular relaxation and anaes- 
thesia begin to appear, indicating the commencement of effusion or accu- 
mulation of inflammatory products, both the salicylate and the calomel 
should be omitted, and in their place from four to six decigrams (gr. vi 
to x) of the iodide of potassium, given every three or four hours, with 
efficient counter-irritation over the affected part of the spine. After the 
operation of the first cathartic the bowels may be moved once each- day by 
enemas. If, prior to the attack, the patient had been anaemic, or under 
the influence of malaria, or other depressing agents, ergot and physostigma 
may be given with the salicylate instead of veratrum vinde or aconite. 
And when the stage for using the iodide comes, it may be alternated with 
from two to three decigram (gr. iii to v) doses of sulphate of quinia with 
advantage to the patient. The treatment I have detailed is such as I have 
found most beneficial in the more acute and severe attacks of spinal 
meningitis in the adult. The same remedies are indicated in the milder 
cases, but they need to be less vigorously used. And in children the amount 
of local bleeding and the doses of medicines should be carefully adjusted 
to the age and vigor of the child. If the symptoms of inflammation sub- 
side without leaving any paralysis of either sensation or motion, very little 
further medication will be required, but the patient must remain at rest 
and carefully avoid undue exertion or excitement, and live on plain, easily 
digestible food until recovery is well established. 

If, however, when all active inflammatory symptoms have disappeared 
some degree of paralysis remains, with soft compressible pulse, cool ex- 
tremities, and general sense of weakness, there must be added to the rest, 
avoidance of excitement and plain nutritious food, the continuance 
of such remedies as will be most likely to hasten the further removal of 
inflammatory products and restore sensibility to the paralyzed nerves. 
For these purposes we have probably no better remedies than moderate 
doses of the iodides with an occasional pill of blue mass at night, the daily 
use of gentle faradic currents, and at a later period, small doses of strych- 
nia with a teaspoonful of the compound syrup of the hypophosphites after 
each meal-time, and judiciously applied massage to the weakened or para- 
lyzed parts To give the patient the best possible chance for recovery, 
the means I have mentioned should be patiently used for a long period of 
time, and the utmost care should be given to the prevention of bed sores 
by scrupulous cleanliness, frequent changes of position, and the aid of air 



MYELITIS. 359 

or water cushions under the parts most exposed to pressure. I next direct 
your attention to 

MYELITIS. 

By this word I mean inflammation of the interior of some part of the 
spinal cord without involving its surface or membranes. 

Attacks of this kind are more frequent in childhood and youth than in the 
middle and later periods of life. It has occurred more frequently in males 
than females. It may arise from the same causes that give rise to spinal 
meningitis, namely mechanical injuries, exposures to cold and wet, excessive 
fatigue, to which may be added as predisposing influences excessive use of 
tobacco, alcoholic drinks, and indulgence of the sexual instinct. The form 
of myelitis that occurs in infants has been observed more frequently dur- 
ing the warm than the cold months of the year, and has sometimes followed 
attacks of the eruptive fevers, as though these exerted a predisposing in- 
fluence. 

Inflammation attacking the substance of the cord may be limited to the 
anterior, posterior, or lateral columns, or it may involve the whole. It 
may be limited to a small section or extend the whole length of the cord. 
It may vary in grade from the most acute to the most chronic form of in- 
flammatory action- Though beginning entirely within the substance of the 
cord, m\ T elitis seldom continues long without extending more or less to the 
surface and involving the pia mater to some extent. 

Symptoms. — The symptoms of acute myelitis differ from those of spi- 
nal meningitis chiefly in the beginning of the attack. The pain in the 
back is more circumscribed ; the initial fever of shorter duration; and the 
paralytic symptoms earlier developed, but much more variable in their lo- 
cation. The latter depends upon the particular parts of the cord involved 
in the inflammation. If the inflammation attacks the anterior gray matter 
of the cord, as is most common in infancy and early childhood (formerly 
called "infantile paralysis,"* more recently Anterior Poliomyelitis,) it 
will be characterized by the sudden development of general irritative 
fever, more frequently in the night, which may vary from a very mild 
grade to a high degree of intensity, accompanied by restlessness, frequent 
pulse, hurried breathing, and dullness or drowsiness, and sometimes, 
though very rarely, convulsions. After a continuance of this fever for a 
period varying from three or four hours to two days, motor paralysis begins 
to be manifested in some part of the system of voluntary muscles ; most 
frequently in those of one or both lower extremities, constituting para- 
plegia and indicating that the inflammation is located in the lower dorsal 
or lumbar part of the cord. I have seen some cases in which the child was 
put in bed at night in apparent good health, and though restless and fe- 
verish during the "last half of the night, but hardly enough to attract special 
attention, yet on being taken up in the morning both legs were found as 
helpless as two strings attached to the body. In other cases only one leg- 
was paralyzed. If the inflammation is located in the anterior gray mat- 
ter of the cervical or upper part of the dorsal portion of the cord, the paralysis 
will be likely to affectone or both arms; and a few cases have been recorded 
in which it involved simultaneously both arms and both legs. When the in- 
flammation is very circumscribed or limited to a small area of the gray matter 
the resulting paralysis may involve only a single muscle or a set of mus- 
cles either on the trunk of the body or on the extremities. In all these 
cases the general febrile symptoms disappear on the supervention of the 

* First well described by Heine in 1840. 



• > 



60 MYELITIS. 



paralysis, and the patients soon regain their appetites and general feelings 
of health, but the paralysis remains with rapidly progressing atrophy ot 
the paralyzed muscles. 

When the disease in the acute form attacks the same parts of the cord in 
adults, the resulting clinical phenomena are the same as in the children, 
except that the initial fever is accompanied by less cerebral symptoms, 
such as vertigo, delirium, and convulsions. When the inflammation in an 
acute form attacks the gray matter of the posterior part of the con I, 
whether in children or adults, the same general febrile symptoms accom- 
pany the first stage, but the pain in the spine is more severe and the sen- 
sory instead of the motor functions are disturbed in different parts of the 
body and extremities. The resulting paralysis is apt to involve the blad- 
der and rectum, while in the cases having the anterior gray matter as the 
seat of the disease, these important parts are unaffected. When the dis- 
ease primarily invades the gray matter of the lateral cornua of the cord, 
the resulting disturbances will be mostly seen in the vasomotor and trophic 
or nutritive. functions. In those rare cases in which the inflammation in- 
vades at once all the columns or tracts of gray matter in the cord, the re- 
sulting paralysis, both sensory and motor, may be so extensive as to inter- 
fere with respiration and lead to an early fatal result. 

Pathological Anatomy. — The structural changes observed as the re- 
sult of acute and subacute inflammation of the substance of the cord, 
are the same as occur in cerebritis. First, congestion of blood in the capil- 
laries and small vessels; second, exudation of liquor sanguinis and leu- 
cocytes into the structure, causing the walls of the vessels, the interstitial 
spaces, and the neuroglia of the nerve matter to be crowded with granule 
and fat cells; and third, swelling and proliferation of the neuroglia-cells, 
with disturbance or disintegration of the axis-cylinders, nerve fibres and 
ganglion-cells, and finally the disappearance of the nerve matter, leaving 
principally fat granules with hypertrophied neuroglia or connective tissue 
and enlarged vessels. To the unaided eye the inflamed parts present at 
different points a variety of colors from the deep red of the stage of con- 
gestion, reddish brown if there be extravasation ; the yellow color of ordi- 
nary exudation; and finally nearly white, while throughout the whole, the 
parts appear more soft than natural, and sometimes almost of a creamy con- 
sistence. 

Diagnosis. — The only period in the progress of myelitis, when there 
could be any difficulty in forming a correct diagnosis, is in the first or febrile 
stage, before marked changes in the sensory or motor functions have oc- 
curred. Even in this brief period, however, if the patient is old enough, 
to express his feelings, the unusual pain in some part of the spine greatly 
increased by motion, should at once suggest the seat of disease. But in 
infants, the fever is often regarded as only evanescent or accidental until 
the paralysis of some part attracts attention. 

Prognosis. — The prognosis in myelitis does not differ much from that of 
spinal meningitis. When the inflammation is located in the cervical and 
upper part of the dorsal portion of the cord and embraces both anterior 
and posterior columns of gray matter it generally proves speedily fatal 
from paralysis of the respiratory organs and muscles. If it is located low 
enough to cause only paraplegia of the lower extremities the patient may 
either make a complete recovery, or recover very good general health 
with permanent loss of motion and diminished nutrition of one or both 
legs, or the continued paraplegia may be accompanied by gradual impair- 
ment of the general health, the formation of bed sores over the hips and 
sacrum and final fatal exhaustion. The same differences in the result maj 



TREATMENT. 361 

attend inflammation in limited areas or tracts of any part of the cord. As 
a general rule, whenever any muscle or set of muscles is so completely 
paralyzed as to be insensible to the galvanic current or to the tendon re- 
flex stimulus, there is little or no prospect of the ultimate recovery of its 
natural function. But so long as there is some response to these stimuli, 
there is a prospect of recovery. In all cases nutrition goes on less rapidly 
in paralyzed parts than in those not paralyzed. This causes, even in 
adults, a paralyzed limb or muscle to soon become smaller than natural; 
and in children who are still growing, the disparity between a healthy 
and paralyzed limb becomes in a few years a marked deformity. 

Treatment. — The therapeutic management of myelitis does not differ in 
any essential particular from that of spinal meningitis. The same reme- 
dies, used in the same manner, and carefully adjusted to the successive 
stages of the disease, may be used as I described in detail when speaking 
of the treatment of the last named affection during the earlier part of the 
present hour. 



LECTURE XXXVIII. 

Chronic Spinal Meningitis, and Myelitis, or Spinal Sclerosis : Their Clinical History, Morbid 
Anatomy, Diagnosis, Prognosis, and Treatment. 

GENTLEMEN: Chronic inflammation of the meninges and substance 
of some part of the spinal cord is of more frequent occurrence than 
the acute and subacute forms of the disease described in the preceding 
lecture. It may be chronic from the beginning and arise from the same 
causes that produce the more active or acute form of disease, or it may be 
the sequel of an acute attack. The chronic form of disease may involve 
a complete section of the cord at any part of its length, or it may be 
limited to the membranes and surface of the cord, or to a part or the 
whole of either the anterior, posterior, or lateral columns of gray matter 
in the substance of the cord. And the detail of symptoms will vary in 
accordance with the variations in the location and extent of the inflam- 
mation. 

Symptoms or Clinical History. — Chronic inflammation of a segment of 
the spinal cord, or transverse meningio-myelitis occurs most frequently 
in the lumbar and lower part of the dorsal region, and next in the cervical 
portion. When in the former it is characterized by persistent pains in the 
loins, increased by bending or motion of the part; sharp, irregular pains 
in the course of the nerves supplying the lower extremities, often accom- 
panied by muscular twitchings, cramps, or persistent rigidity; sensations of 
numbness, prickling, and sometimes heat, especially in the feet and parts 
below the knee. The general symptoms are slight increased frequency of 
pulse; inactive condition of the bowels; a variable condition of the urine, 
being sometimes scanty and red and at others abundant and clear when 
voided but on cooling dppositing a white sediment of ammoniacal or 
phosphatic salts. The muscles most affected are generally the gastroc- 
nemii and soleus by the contractions of which the heel is drawn up and the 
toes strongly flexed. If the disease extends upwards (sclerosis ascendens) 
it will involve in its course the anterior crural and spermatic, causing 



3G2 CHftONIC SPINAL MENINGITIS. 

pains and muscular contractions in the anterior part of the thigh, the 
psoas and iliacus internus, as well as the testicles and cremaster mus- 
cles. At the same time there is liable to be difficulty in regulating the 
passages from the bladder and rectum. The patient may continue in the 
condition I have described from two weeks to as many months, when the 
moderate general febrile symptoms disappear, the pains gradually give 
place to complete anaesthesia or loss of sensibility, and the muscular con- 
tractions to entire relaxation, constituting loss of both sensation and mo- 
tion or complete paraplegia of the lower extremities. If the disease does 
not extend above the level of the lower dorsal vertebra, the patient may 
continue in this condition of paralysis of the lower extremities and enjoy 
fair general health many months or even years. If the inflamed segment 
of the cord be in the neck, it will cause the same succession of changes 
in the muscles and nerves of the trunk of the body and of the upper ex- 
tremities, ending in general spinal paralysis and death. But much the 
larger number of cases of chronic inflammation of the spinal cord involve, 
not a segment of the whole cord, but only one, or even part of one of 
its columns. If it involves the anterior column of gray matter it is de- 
scribed by different writers under the names of anterior spinal sclerosis, 
anterior poliomyelitis; chronic atrophic spinal paralysis; and progressive 
muscular atrophy. If the posterior column of gray matter is the seat of 
disease, it is called posterior spinal sclerosis, posterior poliomyelitis; pro- 
gressive locomotor ataxia, and tabes dorsalis. When located in the 
lateral columns or cornua, it has been designated lateral spinal sclerosis, 
spastic spinal paralysis (Erb.), spasmodic tabes dorsalis (Cheviot), and 
tetanoid pseudo-paraplegia (Seguin). These numerous names used by 
different writers are well calculated to confuse and mislead the student, 
rather than to add to his knowledge of diseases. I shall therefore use 
only the simple designations, anterior, posterior, and lateral spinal sclero- 
sis to distinguish chronic inflammation as limited to one or the other of 
the three principal longitudinal divisions of the cord. 

When the disease is limited to the anterior column of the cord (an- 
terior spinal sclerosis), the chief symptoms are presented in some part of 
the system of voluntary muscles, more frequently in those of the arms, 
shoulders, and chest, but often extending at a later period to those of the 
lower part of the trunk and lower extremities. This order is in many 
cases, however, reversed — the muscles of the lower extremities being 
affected first. The distinctive symptoms are, pricking pains in the affected 
muscles, fibrillary trembling of particular bundles of muscular fibres, pro- 
gressive atrophy or wasting of the muscular structure, and loss of contrac- 
tility or paralysis. In some cases there are coincident pains or rather 
morbid sensations of restlessness in some part of the back, general feel- 
ings of weakness, but no febrile phenomena, and but little derangement 
of the secretory functions. The progress of the disease as indicated by 
the symptoms is very variable. In some cases it may reach such a degree 
of muscular atropine and paralysis as to fatally impair the respiratory move- 
ments, causing death by apncea, in a few months; while in others it may 
require as many years. When the disease is the sequel of an acute attack, 
the progress is usually more rapid and more generally progresses from the 
muscles of the lower extr mities upward to those of the trunk of the body 
and finally to those of the shoulders and arms. There is another class of 
cases which have not been preceded by any acute or active symptoms, but 
which develop mostly in individual muscles, often unconnected with each 
other, as the pectoral, the deltoid, the dorsal interosseous, the muscles of 
the ball of the thumb, the serratus, latissimus dorsi, etc. In some cases 



SYMPTOMS. 3G3 

parallel muscles are affected simultaneously on each side of the body, and 
in others they follow in successive order. 

In some stages of the progress of these cases the patients present a pe- 
culiar and most striking appearance. For instance the muscles of the 
neck, shoulders and chest may be so completely atrophied as to leave the 
outline of each bone as distinct as in the naked skeleton, while those of 
the fore-arms, hips and legs are as full and well nourished as ever. The 
class of cases I have just been describing have been more especially des- 
ignated by many as cases of progressive muscular atrophy, in which the 
disease was primarily located in the muscles, and the gray matter of the 
anterior column of the cord became involved secondarily. This view was 
adopted and maintained with much ability by Friedreich, of Berlin, in 
1873. But whether the disease commences primarily in the muscles or in 
the anterior gray matter of the cord, it is certain that both become seri- 
ously affected during its progress. 

When the disease is confined to the posterior column of the cord (pos- 
terior spinal sclerosis, progressive locomotor ataxia) it is most generally 
located in the cervical portion, but sometimes follows longitudinal tracts 
as low as the lumbar region of the spinal cord. It may also extend in cer- 
tain tracts through the medulla oblongata to the base of the brain. The 

o ... 

characteristic symptoms are manifested chiefly in alterations of sensibility 
in different parts of the periphery of the body, and in impairment of the 
co-ordination of muscular movements. 

There are generally pains in the limbs, sometimes in circumscribed places 
on different parts of the body, accompanied at first by hyperesthesia; and 
at a later period, anaesthesia or analgesia; occasionally dimness of vis- 
ion ; frequent turns of indigestion with some constipation ; inactivity of 
the pupil under chauges in the degree of light; unsteadiness of gait with 
difficulty of going up steps except by a special jerking or springing move- 
ment, and inability to walk in the dark. As the disease advances the loss 
of sensiblity in some parts, more especially in the soles of the feet, is 
more complete : the difficulty of locomotion or walking becomes so great 
that the hands must constantly rest upon something to aid in steadying 
the movements, not because any of the muscles are paralyzed, but for want 
of co-ordination in their action; in some cases either retention or inconti- 
nence of urine ; loss of control over the act of defecation; and entire ina- 
bility to walk or stand upright without support. Early in the disease the 
tendon reflex and the ankle-clonus are notably diminished; and at a later 
period lost. In the early stage, the pulse is moderately increased in fre- 
quency, but diminished in force, and in the later stages of many cases, it 
becomes weak and irregular ; while the temperature seldom varies mate- 
rially from the normal standard. The progress of the disease is generally 
slow; and its duration may vary from six months to twenty-five or thirty 
years. It occurs most frequently in the middle period of adult life ; and 
much more frequently in males than in females. 

When the chronic inflammation is confined to one or both lateral 
columns of gray matter (lateral spinal sclerosis, spastic spinal paralysis, 
tetanoid pseudo-paraplegia,) and occurs as a primary affection, it is gen- 
erally located at the posterior border of the lateral columns proper, and in 
what is caled the crossed pyramidal columns of Flechsig, but in its prog- 
ress may include the larger part of the lateral columns. The symptoms 
which characterize the commencement of this disease, are a sense of weight 
or heaviness in the upper or lower extremities and sometimes in both, 
with great sense of weariness unusually increased by even moderate exer- 
cise. In a little time the weakness amounts to paresis or partial paralysis 



364 CHROXIC SPINAL SCLERDSIS. 

of certain muscles, more frequently of the legs, with slight twltchings or 
tremors, and some stiffness or temporary rigidity following contractions, as 
though the fibres of the contracted muscles could not relax in the usual 
time. For instance in walking, as the body moves forward to the point 
where the weight rests on the ball of the toes with the heel up, the failure 
of the muscles to relax at the proper moment, keeps the toes down until 
the patient may be in danger of falling forward, and gives him a pecul- 
iarly stiff and jerky gait. At this stage, both tendon reflex and ankle- 
clonus are much increased, being the reverse of their condition in the 
anterior spinal sclerosis. But there is neither muscular atrophy nor im- 
pairment of the functions of the bladder, rectum or sexual organs as occurs 
in the posterior spinal sclerosis. Still the symptoms I have enumerated 
as characteristic of the lateral sclerosis continue slowly to increase until 
the patient loses all power over the extremities, upper and lower, and 
many of the muscles remain in a state of rigid contraction, constituting 
an entirely helpless condition. In this state he may live many years, the 
mental faculties and nutritive functions remaining active and efficient, 
until some other disease supervenes to cut life short. The same grade of 
disease may extend to, or primarily attack the motor nuclei of the medulla 
oblongata, causing pains in the neck at the junction with the back of the 
head and sometimes dizziness; slowness of speech and mastication, with 
drooping of the lips and angles of the mouth, allowing dribLtiing of saliva; 
and a little later, difficulty of deglutition, great feebleness of voice, and 
sometimes distressing paroxysms of d\ r spnoea. While retaining the mental 
faculties and general sensibility unimpaired, all the disabilities I h..ve 
named continue to increase until the ability to swallow is entirely lost, 
and the patient is in danger of death from ultimate starvation. When 
the disease develops thus, in the tracts of medulla I have named as a 
primary affection, it constitutes the ghicso-labio-laryngeal paralysis of 
Trousseau, or the JBulbo- nuclear sclerosis of other writers. While most 
of the cases of lateral spinal sclerosis affect both lateral ptrts of the cord 
at the same time, and consequently involve the muscular movements in 
both arms or legs coincidently, there are some instances in which the dis- 
ease is unilateral, and others in which the disease in one side follows 
after that in the other. It is proper to state also, that lateral spinal 
sclerosis in its progress often extends into some parts of the anterior col- 
umns of gray matter, causing the case to be complicated with more or less 
of the symptoms of anterior spinal sclerosis. This constitutes what has 
been described by Charcot, as "Amyotrophic lateral sclerosis," but better 
termed antero-laterai sclerosis. The same may be said in regard to the 
extension of lateral sclerosis posteriorly into the posterior column of gray 
matter, by which the symptoms of lateral sclerosis become more or less 
complicated with those of locomotor ataxia and may be distinguished as 
posterio-lateral sclerosis. 

Again, cases are met with in which there is more or less intermingling 
of symptoms belonging to sclerosis of all parts of the cord and medulla. 
These have been designated as multiple or disseminated spinal sclerosis. 
They may present the paresis or weakness and dragging of the limbs, fol- 
lowed by twitching or trembling, as in lateral sclerosis; with the pains 
and varied conditions of nerve sensibility belonging to posterior spinal 
sclerosis; and the well marked atrophy of some of the muscles as in anterior 
sclerosis. These multiple or mixed cases may present a great variety of 
symptoms and phases, according as one set of symptoms or another pre- 
dominate. 

Morbid Anatomy. — While chronic inflammation or sclerosis in different 



MORBID ANATOMY. 3G5 

parts of the spinal cord, gives rise to different symptoms, according to the 
functions of the part involved, yet the molecular or structural changes 
which take place during its progress are substantially the same in what- 
ever parts it may be developed. These changes are, first, dilation of the 
capillaries and smaller vessels, with exudation or permeation of their 
walls by leucocytes and other elements of the blood, followed by hyperplasia 
from enlargement and proliferation of the cell elements; and second, simi- 
lar hyperplasia of neuroglia, nerve-sheaths, and reticular or connective 
tissue, and corresponding atrophy and disappearance of the nerve-cells 
and medullary matter of the nerve tubules, leaving the axis-cylinders 
either of normal size or even hypertrophied. These changes, which are 
apparent fully, only when the structure is properly prepared and examined 
under the microscope, give to the sclerosed part greater density or hard- 
ness, which is apparent to the touch or when cutting through it, and to 
the eye shows a gray or yellowish gray color, and sometimes, after expos- 
ure to the air, a redder tint. The cut surface has a smooth, even appear- 
ance, and there exudes from it only a small quantity of transparent fluid. 
In the anterior spinal sclerosis these changes will be found chiefly in the 
anterior gray matter of the cord, and in some cases extending to the 
anterior roots of the spinal nerves. In the posterior and posterio-lateral 
sclerosis they are found in some part of the gray matter of the posterior 
column, more generally in its cervical portion, and in the posterior roots 
of the spinal nerves; while, in some cases, they are found as low as the 
lumbar part, and in others as high as the base of the brain. In the lateral 
spinal sclerosis, the altered patches or tracts of the cord are found mostly in 
the posterior margin of the lateral column ; while in the complex or multiple 
cases of sclerosis, patches of sclerosed structure will be found in all 
divisions of the cord, often very irregularly or unequally distributed. For 
details as to the best methods of preparing specimens and examining them 
under the microscope, I must refer you to my colleague in the chair of 
pathology and pathological anatomy, or to the text-books in that depart- 
ment. 

Diagnosis. — The chief symptoms characteristic of sclerosis of the several 
parts of the spinal cord I have already pointed out with sufficient emphasis 
in giving their clinical history. From corresponding forms of disease in 
any part of the brain, they are distinguished by the absence of direct 
cerebral symptoms and the restriction of morbid phenomena to the muscles 
and parts supplied with nerves from the spinal cord. 

From all the varieties of functional and reflex disturbances of the nervous 
system, they are distinguished by their gradual development, persistent 
progress, and in most cases by their involvement of progressive atrophic, 
or wasting nutritive changes in the muscular structures connected with 
the diseased portions of the spinal cord. In the purely lateral sclerosis in 
which there is not marked muscular atrophy, but often quivering and 
trembling of muscles after voluntary movements, there may be danger of 
confounding it with paralysis agitans or shaking palsy. 

The latter, however, exhibits a much finer and more purely tremulous 
motion, commencing and continuing without the slightest connection with 
voluntary motion; while the shaking of lateral sclerosis is a coarser motion, 
chiefly accompanying and following voluntary movements, and manifest- 
ing itself quite as often in irregular motions of the head as of the hands or 
feet. 

Prognosis. — When spinal sclerosis has become well developed in any 
part of the cord it is seldom cured by any process of treatment. And yet 
cases have occurred in which recovery took place when the symptoms were 



366 CHRONIC SPINAL SCLEROSIS. 

so strongly characterized as to leave no reasonable doubt concerning the 
correctness of the diagnosis. A few such cases, more particularly of the 
posterior spinal sclerosis — progressive locomotor ataxia — have come under 
my own observation. The eariier chronic inflammation in any part of the 
cord is detected and brought under judicious treatment the better is the 
prospect of success. The slowness of development and the equivocal 
character of the earlier symptoms of this form of disease, cause the real 
nature of many cases to pass without recognition until the changes of 
structure have become permanent. As constitutional syphilis and habitual 
use of alcoholic drinks are among the more frequent and recognizable causes 
of spinal sclerosis, it is highly probable that an early and correct diagnosis 
accompanied by the use of proper sanitary measures and remedial agents 
would arrest the further progress of the morbid action in a large propor- 
tion of the cases, and thereby postpone the development of the more dis- 
tressing symptoms for many years. So long as the sclerosis does not in- 
volve those parts of the medulla oblongata controlling respiration, or of 
such parts of the cord as are connected with urination and defecation, life 
and a fair degree of health may be continued from five to fifty years; or 
until the patients die from some intercurrent disease. Dr. J. W. Holland 
recently reported to the Louisville Medico-Chirurgical Society three 
cases of disseminated or multiple sclerosis of the spinal corJ in one 
family, which consisted of one brother and four sisters, the brother and 
two of the sisters being affected with the disease, while the other two are 
exempt. In the brother the first symptoms of disease were manifested 
when he was twelve years of age, and have now been slowly progressing 
fifteen years. The two sisters began to be affected when eleven years of 
age, and in one it has continued six years and in the other two years.* 
Both parents and the other two sisters are free from all symptoms of spinal 
disease, and no cases were known to have occurred in the ancestry. The 
occurrence of three cases in one family, all commencing at nearly the 
same age, and that so early as the eleventh and twelfth years is very 
unusual. 

Treatment. — Although the treatment of all varieties of spinal sclerosis 
or chronic myelitis, has failed to effect a cure in the great majority of 
cases, yet there are certain rational indications to be fulfilled, which, if ju- 
diciously attended to through a long period of time, will greatly mitigate 
the suffering of the patients, prolong their lives, and occasionally result in 
a positive recovery. • 

In the earlier stage while there is pain, hyperesthesia, or disturbance 
of muscular action, indicating that the nerve-cells and medullary matter 
are not altogether lost but still retain a degree of structural integrity, the 
leading objects of treatment are, to overcome the morbid excitability of 
the structure and thereby lessen the pain and muscular rigidity or irregular 
muscular contractions; to arrest the morbid molecular movements by 
which the connective tissue of the part is becoming hypertrophied from 
hyperplasia or excess of nutrition and the contained nerve matter atro- 
phied; and to so regulate the habits, mental and physical, as to avoid the 
further action of either the predisposing or exciting causes. To ac- 
complish the latter, the patient should be required to avoid all use of alco- 
holic beverages, whether fermented or distilled; all use of tob.icco; and 
all sexual indulgences. 

• He should live on plain, easily digestible, and nutritious food, including 
meat with tea and coffee, rather sparingly. You should also enjoin much 

* See Louisville Medical News, Vol. XIV., No. 363, p. 28R, Dec, 9, 1882. 



TREATMENT. 367 

rest in the recumbent position. If the patient is capable of taking any 
exercise out-doors, let it be mostly passive by riding, never allowing long 
walks or long standing at one time. And it is an important rule to have the 
patient place himself fully at rest in a position to give the whole system of 
voluntary muscles as complete relaxation as possible, after every effort at 
physical exercise or exertion. My own clinical observations lea:l me to 
think that this rule in regard to full rest, is deserving of more attention 
than it has generally received in ths management of this class of diseases. 
If the case comes under your care quite early in the progress of the disease, 
you will often derive advantage from efficient dry cupping over the spine 
every third day for two or three weeks, with frequent sponging of the back 
with tepid water during the interval between the cuppings. The severer 
forms of counter-irritation by blisters, setons, issues, moxas, and the hot 
iron have all been used freely in many cases, but without material benefit. 
In a few cases, I have followed the dry cupping and hot water sponging 
by a succession of small blisters, with some benefit; and have followed 
these by the use of the camphorated soap liniment, holding in solution 
six centigrams (gr. i) of veratria to each thirty cubic centimeters (fl. fi) 
of the liniment, applying it freely over the spine each morning and 
evening. To fulfill the two indications first named, we need the influence 
of such anodynes as will lessen morbid sensibility without checking the 
necessary secretions and evacuations, combined with some efficient alterant 
capable of diminishing the exaggerated play of vital affinity by which the 
molecular movements constituting cell-proliferation and hyperplasia of the 
connective tissue in the diseased parts are regulated. The anodynes best 
adapted to fill the requirements specified are the stramonium, hyoscyamus, 
and coniura; the opiate preparations, though more efficient as anodynes, 
being too liable to produce constipation and to diminish many of the 
secretions. The most reliable alterants are the bichloride of mercury and 
the iodides. And during the same period of time that I have advised dry 
cupping and hot water sponging externally, I have been in the habit of 
giving internally a combination of the bichloride of mercury and iodide 
of sodium with the tinctures of stramonium or hyoscyamus and either the 
cimicifuga racemosa, phytolacca decandra, or senecio aureus, as in the 
following formula: 

T£ Hvdrarofvri Chloridi Corosivi 0.1 grams. gr. 1^ 

Sodii Iodidi 15.0 " 3iv 

Tincturse Stramonii 15.0 c.c. 3iv 

Tincturae Phytolaccse Decandrse 75.0 " ?iiss 

Elixer Simplices 60.0 " fii 

Mix. Give to an adult four cubic centimeters (fl. 3i ) in a little 
additional water each morning, noon, tea-time and bed-time. After two 
or three weeks I usually limit the use of this combination to one dose in 
the morning and evening, and commence giving, after each meal-time, 
some one of those remedies that are supposed to promote general nutrition, 
such as the syrup of lacto-phosphate of calcium; the compound syrup of the 
hypophosphites of sodium, calcium, and iron, etc-, in conjunction with the 
phosphide of zinc. If at any time the gums or breath show any indica- 
tions of the mercurial action, I immediately omit both the bichloride of 
mercury and the iodide of sodium, and supply their place with fair doses 
of the iodide of potassium. 

If the bowels fail to move regularly they should be aided by enemas or 
mild laxatives. Unless I have erred much in my diagnoses, I have seen 



3G8 CHRONIC SPINAL SCLEROSIS. 

a considerable number of cases of true chronic myelitis, affecting different 
parts of the spinal cord, recover, in which the foregoing management was 
commenced soon after the characteristic symptoms were manifested, and 
was continued with steadiness and perseverance for many months. 

If, however, either from the late stage at which the case comes under 
your care, or in spite of the foregoing or any other treatment, you find the 
pain and hyperesthesia giving place to anaesthesia, and muscular con- 
tractions yielding to motor paralysis with increasing atrophy of the affected 
muscles, you may add to your remedial measures the daily use of mild gal- 
vanic currents in connection with friction and massage, continued from 
ten to twenty minutes each day, with a reasonable expectation of retard- 
ing the progress of the disease, and rendering the patient more comfortable 
if you can not effect a cure. One of the obstacles to your success in the treat- 
ment of these slow chronic affections of the spinal cord, will be that im- 
patience and restless desire to see speedy results, which often induces both 
patient and physician to make such frequent changes from one remedy, or 
one method of treatment, to another, that no one agent or process is con- 
tinued long enough to give a fair opportunity for developing its effects 
either for good or evil. Another obstacle of importance will be a tend- 
ency, encouraged by much of what is published in the current medical 
literature, to try specific remedies more or less indiscriminately, instead 
of endeavoring to carefully appreciate the exact pathological conditions 
and stage of progress in each case, and selecting and adjusting remedies 
thereto on rational principles guided by a knowledge of themodus operandi 
of the remedial agents selected. My remarks thus far, gentlemen, have 
relation to the management of chronic inflammation during its progress, 
and before the morbid process called sclerosis is complete. But when the 
cases coming under your charge have advanced so far that paralysis of either 
sensation or motion, or both, is complete, and the muscular structures in- 
volved greatly atrophied, indicating entire disintegration or disappearance 
of the nerve structure in the sclerosed patches or nerve tracks, there is left 
no reasonable hope of recovery; and the only rational indication for treat- 
ment is to so regulate the diet and hygienic surroundings of your patients, 
with such careful attention to the palliation of symptoms, the prevention of 
bed sores, the securing of proper evacuation from bladder and rectum, as will 
render them most comfortable, and best contribute to the maintenance of 
general health. Yet, it is best not to be too positive in pronouncing par- 
ticular cases hopeless. For I well remember a case of well marked loco- 
motor ataxia or posterior spinal sclerosis that came into my wards of the 
Mercy Hospital a few years since. The patient was a working man, about 
thirty-five years of age, who had been much exposed to cold and wet, and 
was somewhat addicted to the use of alcoholic drinks. The symptoms of 
locomotor ataxia had been progressively developing for three months 
before his admission to the hospital. The diagnostic symptoms of the 
disease were at that time so complete that he was several times presented 
to the clinical class for illustrating the progress of typical cases of that 
affection. I subjected him to steady treatment for three months, embrac- 
ing in succession, alteratives, tonics, nutrients, electro-magnetic currents, 
and judicious diet; but rather encouraged him to try to walk every day a 
few minutes at a time, which was doubtless an error. At any rate he 
steadily failed until at the end of the three months he could not walk a 
step or stind upon his feet without an assistant on each side to hold him up. 

Thinking further special treatment of no use, he was directed to desist 
from all efforts to maintain an upright position even long enough for the 
making up of his bed; but to have strict attention given to cleanliness, 



NEURITIS. 309 

frequent changes of position in bed to avoid bed sores, proper attention 
to his evacuations, a plain nutritious diet, and no medicine except at each 
meal-time eight cubic centimeters (fl. 3ii) of a mixture of two parts of a 
thick syrup called extract of malt and one part of compound syrup of 
hypophosphites. He was left entirely at rest under these directions, ex- 
pecting him to continue failing until a fatal result was reached. But much 
to my surprise after about three months of this rest, he began to make 
etforts to help himself, and in another month could get out of bed and 
stand alone, and finally so completely recovered that he left the hospital 
with a steady firm step and gait in walking, and in fair general health. I 
relate the case, first to show that patients sometimes recover from condi- 
tions of chronic disease which render their cases apparently hopeless; and 
secondly to illustrate the value, in some cases at least, of entire and pro- 
tracted rest in the recumbent position. 

Neuritis. — Both the sheaths and substance of the various nervous cords 
are liable to attacks of inflammation in all degrees of activity. Specimens 
of this are seen most frequently in the roots of the spinal nerves, the 
trunk of the sciatic, and in the tri-facial, than elsewhere. The inflamma- 
tory process almost always partakes of the rheumatic character, and is 
most readily relieved by anti-rheumatic treatment, aided by narcotic fo- 
mentations in the first stage, and subsequently blisters over the affected 
nerves. I have now completed the consideration of inflammations of the 
nervous apparatus, so far as the time allotted to our present course will 
permit. 



LECTURE XXXIX. 

Inflammation of the Respiratory Organs ; The Several fractures included under this Head, and 
their ubdivisions —Historical and Etiological Considerations.— Acute and Chronic Inflammation 
otthe Naso-Pharyngeal Membrane; Their Symptoms, Diagnosis, Prognosis and Treatment. 

GENTLEMEN: The organs immediately concerned in the process of 
respiration, are the nasal, laryngeal, tracheal and bronchial tubes, the 
parenchyma of the lungs, and the pleura covering the latter. Considered 
in regard to the inflammations we are about to study, they are composed 
of three important structures, namely: The mucous membrane linii g the 
tubes and over which the air has to pass in going to and from the air-cells 
of the lungs; the parenchyma of the lungs; and the serous membrane 
called pleura, which not only forms the outer covering of the lungs, but 
also constitutes the lining of the walls of the chest. Each of these struct- 
ures are liable to attacks of inflammation separate from the others, and in 
each the inflammatory process is modified in its progress and results by 
the peculiarities of structure and function belonging to each part. In 
this connection I might mention a fourth structure consisting of the mus- 
cular and fibrous layers of the bronchial tubes which are sometimes the 
seat of inflammation, as you will learn hereafter. 

History. — Inflammation located in the respiratory organs, has been rec- 
ognized as a frequent and serious form of disease from the earliest periods 
of medical history; both as an idiopathic affection and as a complication of 
most of the acute general diseases. It was not until the latter part of the 
24 



370 INFLAMMATION OF THE RESPIRATORY ORGANS. 

eighteenth century that any considerable attempts were made to differen- 
tiate between inflammation in the membranous structures and in the paren- 
chyma of the lungs. And even those attempts were attended by only a 
limited degree of success until after Lnennec had constructed a stethoscope 
and directed the attention of the profession to the application of the 
knowledge of the laws governing the production and transmission of 
sounds to the study of the clinical phenomena of pulmonary diseases. 

Since that period of time, the familiar practice of auscultation and per- 
cussion, added to the study of the general symptoms, has rendered the 
diagnosis of disease in any part of the respiratory organs as exact as that 
of any class of diseases to which the human system is liable. You have 
already acquired, in connection with the courses on general pathology 
and clinical diagnosis in the hospital and dispensary, during the second 
year of your studies, such a degree of familiarity with the whole subject 
of physical diagnosis as to render any elementary consideration of that 
subject unnecessary at this time. I shall proceed, therefore, directly to 
the consideration of the different grades of inflammation affecting the 
several structures of which the respiratory organs are composed, in the 
following order: First, those of the mucous membrane; second, those of 
the parenchyma of the lungs; and third, those of the serous membrane or 
pleural covering of the lungs. For more convenient and accurate descrip- 
tion, those of the mucous membrane may be divided into such as affect 
the lining of the nasal passages or Schneiderian membrane; the lining of 
the larynx and trachea, and the lining of the bronchial tubes. As all 
these sections of the mucous membrane are constantly exposed to contact 
with the inhaled air, containing whatever impurities may be suspended in 
it, and almost constantly varying in its temperature, moisture, and electric 
states, so we find some degree of inflammation affecting them, more fre- 
quently, perhaps, than any other structures in the human body. And, as 
a general rule, their frequency in any given locality with an equal popu- 
lation, will be in a direct ratio to the frequency and severity of the atmos- 
pheric changes. Consequently you will find them most prevalent in those 
parts of the temperate zone, the climate of which is characterized by fre- 
quent and extreme changes in temperature, coupled with a high degree of 
atmospheric moisture and severe winds. For the same reason you will 
meet them most frequently in the cold season of the year, or, more accu- 
rately, during the last half of autumn and the first part of spring, when the 
atmospheric vicissitudes are most sudden and severe. The parts of our 
own country in which these characteristics of climate and season are most 
prominent, are embraced in the belt or zone lying north of the 40th 
parallel of latitude, and extending from the Atlantic Coast to the foot or 
eastern border of the great mountain ranges that separate the waters 
which flow into the Atlantic and Gulf of Mexico from those flowing into 
the Pacific Ocean. On the other hand, they are least prominent in the 
belt or zone lying south of the 33d parallel of latitude, and on the 
Pacific Slope, west of the great mountain ranges just mentioned. The 
prevalence of inflammations of the parenchyma of the lungs and of the 
serous membrane covering them, follow a different rule or law. Instead 
of being most prevalent in those climates characterized by a predominance 
of the cold season over the warm, accompanied by the most frequent and 
extreme changes in the thermometric and hygrometric conditions of the 
atmosphere, they occur most frequent and most severe where the summer 
heat is long and high and the winter short, yet giving some days of very 
low temperature, thereby making a wide range between the hottest days 
of summer and the coldest of winter, with a predominance of summer heat. 



ETIOLOGY. 371 

This, in the United States, corresponds with the middle climatic belt or 
zone, hounded on the north by the 39th and on the south by the 33d 
parallel of latitude, and extending from the eastern foot of the Rocky 
Mountain chain to the Atlantic Coast. From these general remarks, I come 
now directly to the separate study of the 

INFLAMMATIONS OF THE MUCOUS MEMBRANE OF THE AIR PASSAGES. 

Etiology. — As the same causes tend to produce inflammation in all parts 
of the respiratory mucous membrane, it will economize time and avoid 
repetition to study them in their relations to the whole extent of the mem- 
brane at once. They may be divided into two classes: predisposing and 
exciting. The first embrace all agents and influences that are capable ol 
rendering the mucous membrane of the air passages more susceptible to 
impressions. This may be done by directly increasing the irritability of 
the structure, or by altering the quality of the blood and lessening the tone 
of the smaller vessels. The second embraces such agents and influences 
as are capable of so increasing the irritability of the membrane, coupled 
with such alteration in the action of the blood-vessels as to induce a direct 
accumulation of blood in the capillaries of the part. 

The most common and important of the predisposing causes may be 
grouped under the heads of age, occupation, modes of life, or personal 
habits; climatic conditions, and season of the year. 

Age. — A careful examination of the statistics of mortality resulting from 
inflammations of the membrane lining the air passages, has led to the infer- 
ence that childhood and old age are much more susceptible to attacks of 
this form of disease than the middle period of adult life. Consequently, 
nearly all your text-books on practical medicine represent childhood and 
old age as exerting a decided predisposing influence in favoring attacks, 
while the active period of adult life is comparatively exempt. A more 
extended examination of the subject, however, has shown that of a given 
number of attacks at different periods of life, a very much larger ratio of 
deaths result in early childhood and old age than in the middle period of 
life. Indeed, this increased ratio of mortality at the two extremes of life, 
in proportion to the whole number of cases, is sufficient to account for the 
results shown by the mortuary statistics, without supposing that the number 
of cases occurring in middle life are any less in proportion to the number of 
persons than in childhood or old age. On the contrary, my own records of 
cases of acute diseases, without regard to the mortality, show a larger ratio 
of attacks of inflammation in some part of the mucous membrane of the air 
passages, between the ages of fifteen and thirty years, than at any other 
period of life. I am now speaking of the inflammatory attacks as they 
occur independently, and not as complications of some of the acute gen- 
eral diseases, such as epidemic influenza, typhoid fever, measles, etc. 

Occupation. — You will find all such occupations as confine those pursu- 
ing them much in-doors, to strongly predispose to attacks of catarrhal 
inflammation in the air passages. And if the air of the rooms occupied is 
kept at a temperature either too high or too low, the predisposition will 
be much increased. Habitual exposure to a warm and confined atmos- 
phere, by inviting free exhalations from the membranous surfaces and 
increasing their susceptibility, renders them more sensitive to all external 
impressions. On the other hand, much confinement in rooms at a low tem- 
perature, represses the exhalations from the cutaneous surface, thereby 
causing the retention of some of the products of tissue changes in the 
blood, which renders the individual more susceptible to attacks of inflam- 



372 INFLAMMATION OF THE AIR PASSAGES. 

mation in any of the structures of the body on the supervention of an 
exciting case. 

Personal Habits. — For the reasons just stated, the wearing of too much 
or too little warm clothing, also either increases the relaxation and suscep- 
tibility of the skin and respiratory membranes from the former, or holds the 
cutaneous exhalations in check and increases the retention of w T aste and 
irritating material in the blood from the latter. 

Another error of importance is the unequal adjustment of clothing to 
different parts of the cutaneous surface. On children, especially, you 
often see an abundance of warm clothing over the whole body, while the 
legs and feet and neck have but a single covering and sometimes none. 
And even adult women often go out loaded with warm clothing, while 
their feet and ankles are protected only by thin shoes and stockings. 

Climatic Conditic ns. — It is universally conceded that inflammation of all 
parts of the mucous membrane lining the air passages, prevails most in 
such countries as are characterized by a cold, damp, and variable climate. 
This can be well illustrated by comparing the prevalence of this class of 
diseases in that belt of our own country lying north of the 39th parallel 
of latitude and east of the Rocky Mountains, with the prevalence of the 
same diseases in the belt south of the 33d parallel and bordering upon the 
Atlantic and Gulf of Mexico. In the former the summers are compara- 
tively short with brief periods of high temperature; the winters cold; and 
the transition seasons, spring and autumn, long and exceedingly variable 
with a predominance of cold and dampness. In the latter, all the condi- 
tions just mentioned are substantially reversed. 

Perhaps the earliest reliable statistics we have bearing upon this subject, 
are those collected by Dr. Samuel Forrey from the several military posts 
occupied by the United States Army, and given in a series of articles in 
the American Journal of Medical Sciences, and subsequently in an octavo 
volume, on the climate of tiie United States and its influence over the prev- 
alence of diseases. The valuable facts presented by Dr. Forrey were added 
to by Dr. Daniel Drake and given in full in his large work on the topog- 
raphy and diseases of the great interior valley of this continent. From 
these sources you can learn that the average annual number of attacks of 
inflammation of the mucous membrane of the respiratory passages in every 
1,000 soldiers at Fort Snelling, in Minnesota, lat. 44° 53' N., was 600. At 
Fort King, fifty miles from the Gulf of Mexico, lat, 28° 58' N., the annual 
number of attacks average only 101.2 in every 1,000 persons. Again, at 
Madison Barracks near Sackett's Harbor, in New York, the average num- 
ber of attacks for every 1,000 persons was 637.2; while at Key West, in 
Florida, the average number of attacks was 208.9, and at Baton Rouge, 
Louisiana, only 207.2. Dr. Drake after a laborious comparison of the sta- 
tistics at all the military posts in the great interior valley from Fort Snell- 
ing at the north to Fort Jessup in Louisiana, the most southern, makes the 
"ratio of decrease in bronchial inflammations" as we pass from the north 
to the south as hi. 5 for each degree of latitude.* A similar comparison 
of the statistics of all the posts on the Atlantic Slope from Madison Bar- 
racks to Key West will give you nearly the same result. 

A study of these same military statistics, representing the mean ratio of 
the prevalence of diseases of the respiratory passages for a period of ten 
years at nearly all the posts, will justify some other inferences of interest 
beside the one just stated. According to this general inference or rule, 

* See a Systematic Treatise on the Principal Diseases of the Interior Valley of North America, 
etc., etc, Secoud Series, pp. 795-6. 



ETIOLOGY. 373 

the three important factors in the climates most favorabie for producing 
inflammations of the air passages are cold, variableness, and dampness; 
the latter being emphasized by most writers as of predominating influence. 
Yet the tables to which I am directing your attention show that the 
highest ratio of prevalence of inflammatory attacks of the mucous mem- 
brane of the respiratory passages in the northern part of the interior valley, 
was at Fort Snelling, in the immediate vicinity of fcst. Paul, Minnesota, 
being 600 attacks for every 1,000 soldiers; while the lowest ratio was at 
Fort Dearborn, on the site now occupied by the city of Chicago, being 
on?y 102 for every 1,000 soldiers. Looking at the posts in the eastern 
part of the northern belt of country, Madison Barracks, at Sackett's Harbor, 
at the eastern end of Lake Ontario, gives a ratio of 637 attacks for every 
1,000 soldiers; while Fort Niagara at the mouth of Niagara River near 
the western end of the same lake, gives a ratio of only 355. Again 
tinning to the posts in the southern belt of country the tables show at 
Fort Jessup in the interior of western Louisiana, a ratio of 432.8; while at 
Fort Jackson the ratio was only 47.5, and at Fort King 101.2. As Fort 
Snelling is on the high rolling prairie of the interior of Minnesota, noted 
for its cold and dry air, and Fort Jessup on the elevated, arid plateau 
between the head waters of the Sabine and the Red river, they cannot be 
noted for a high degree of atmospheric moisture. On the other hand, Fort 
Dearborn was located near the mouth of the Chicago river, on the site 
now occupied by this city (C.icago), which was then a low and wet 
prairie with a sub-stratum of impervious clay, giving all the conditions 
favorable for the prevalence of a high degree of atmospheric moisture. 
And Forts Jackson and King were both on low alluvial lands only fifty 
miles from the Gulf. Again, Fort Niagara is surrounded by all the con- 
ditions favoring a high degree of atmospheric moisture certainly equal to 
those surrounding Madison Barracks in nearly the same latitude; and yet 
the ratio of attacks in the latter was nearly double those in the former. 
It will be evident to you, therefore, that there must exist some important 
factor in the climatic relations of the inflammatory affections of the res- 
piratory passages, besides temperature, humidity, and changeableness. 
A glance at the topography of the whole country will show you that each 
of the posts giving a high ratio of attacks, namely, Madison Barracks and 
Forts Snelling and Jessup, to which may be added Forts Gratiot, Craw- 
ford, and Wood, are so located as to be exposed to the prevalence of unu- 
sually severe winds or atmospheric currents either from the north-east up 
the valley of the St. Lawrence to Madison Barracks, or the north-west and 
west to Forts Snelling and Jessup, with certain relations to high mountain 
ranges in the west and ocean currents in the east. That the high ratio of 
attacks of catarrhal affections at Madison Barracks is largely due to the 
influence of the winds I have alluded to, is corroborated by the fact that 
the same diseases are much more prevalent in the province of Quebec, 
through which the valley of the St. Lawrence extends, than in the province 
of Ontario, as shown by the Register General's report in reference to the 
several military posts in the Canadas. 

And it is equally evident that the high ratio of prevalence of the same, 
diseases at Forts Snelling, Crawford and Jessup is also large! v due to the cold 
and strong atmospheric currents that sweep over the plains from the north- 
west and west with such force as to justify the popular title of "blizzards." 
I may safely say, therefore, that the force and direction of atmospheric 
currents have quite as much to do with the development of inflammations of 
the air passages, as either temperature or humidity. 

Season of the Year. — As might be inferred from what has alreadv been 



o74 INFLAMMATION OF THE AIR PASSAGES. 

said in relation to the influence of climatic conditions, those parts of the 
year characterized by low temperature, high winds, and frequent thermo- 
metric changes are accompanied by the highest ratio of prevalence of inflam- 
mations of the respiratory passages. This is fully shown both by the sta- 
tistics compiled from the records of all the military posts by Dr. Drake,* 
and by the results of clinical records kept under my own observation 
through a series of years. 

Exciting Causes. — Exposure to sudden and extreme changes in atmos- 
pheric temperature from warm to cold, is almost universally regarded as 
the chief exciting cause of inflammation in any part of the mucous 
membrane of the air passages. More accurate and detailed observations, 
however, show that such changes of temperature are seldo »« productive oi 
diseases of this class unless accompanied by coincident high winds and 
humidity. My own studies concerning the relations between special me- 
teorological conditions, and the prevalence of particular diseases have led 
me to the following conclusions in regard to inflammation of the mucous 
membrane of the air passages. 

First. Many sporadic cases are caused at any and all seasons of the year 
by exposure of limited portions of the cutaneous surface to cool or cold 
currents of air, while the rest of the body is well protected. 

Second. The sudden transition from a protracted period of intense dry 
cold, to a higher temperature with increased atmospheric humidity. Almost 
every winter season in the northern belt of the United States east of the 
Rocky Mountains, is characterized by several periods of steady dry cold air, 
varying from one to three weeks in duration, during which the mercury in the 
thermometer often descends more than 20° C. (8° to 10° F.) below zero, and 
which generally end in a sudden change in the direction of the winds, and a 
marked elevation of m temperature, constituting what is popularl}- called 
" a thaw." Such changes are very uniformly accompanied by a general 
prevalence of catarrhal affections of the air passages. 

Third. The occurrence of those cold north-east winds that, during the 
latter part of autumn and early part of spring, so oiten sweep over the 
whole extent of our Atlantic coast, and press up the valley of the St. 
Lawrence to the great interior lakes; and the still more severe currents 
that come during the s^ me seasons from the north-west and west over 
all the wide plains that intervene between the great mountain chains to 
the west, and the upper lakes and Mississippi river to the east, are also ac- 
companied by a high ratio of prevalence of the diseases now under con- 
sideration. Most of these severe storms of wind are accompanied by 
either snow or rain, and a marked increase of ozone or active oxydizers. 
In some of the severe snow storms from the north-east occurring in the 
latter part of February and in March I have found an unusual amount of 
free ammonia. Whether either the ozone or the ammonia has anything 
to do with the production of the catarrhal affections remains to be determined 
by more exact observations and records. 

Acute Inflammation in the Nasal Passages. — Acute and subacute in- 
flammation in the Schneiderian membrane, more familiarly known as acute 
nasal catarrh, is a disease of very frequent occurrence in all the northern 
part of our country, as I have shown while speaking of the etiological re- 
lations of climate. 

It usually commences with a sense of heat, dryness, and fullness, in the 

* See Drake on the Principal Diseases of the Interior Valley of North America, p. 792. 



SYMPTOMS. 375 

nostrils ; a watery appearance of the eyes; frequent sneezing ; dull pain in 
the forehead and temples; sometimes rigors or chilliness ; followed by 
slight general fever, and acceleration of pulse. In from twelve to eighteen 
hours, the heat and dryness in the nostrils give place to the secretion of a 
thin water colored mucus that increases in quantity until at the end of 
twenty-four hours it will require the constant use of a handkerchief to 
keep it from dripping from the nostrils. The Schneiderian membrane is 
red and tumefied from the intense injection of the vessels, and this redness 
often extends from the posterior nares over a part of the pharynx and arch 
of the fauces, while the tumefaction of the membrane over the turbinated 
bones and in the middle part of the nasal passages so nearly closes them 
as to prevent getting the breath except by opening the mouth. This is 
particularly annoying to nursing children who can take but one or two swal- 
lows of milk from the breast before they are obliged to let go the nipple to 
take in breath through the mouth. In most cases in from twenty-four to 
forty-eight hours after the commencement of the attack, the heavy, dull, 
feeling in the forehead begins to abate, the secretion in the nostrils begins 
to be thicker and flows less freely; and in another day it becomes whitish, 
opaque, or muco-purulent. At the same time the tumefaction of the 
membrane begins to abate, and there is less trouble in breathing through 
the nostrils, except after sleeping when the accumulation of thick muco- 
purulent matter necessitates free blowing of the nose to clear it away be- 
fore the breathing can go on well in the morning. In most of the acute 
cases the decline of the inflammation is sufficiently rapid to allow the pa- 
tient to regain free use of the nostrils and exemption from further annoy- 
ance in from five to seven days. Such is the most common course of acute 
inflammation in the membrane lining the nasal passages, as it occurs in 
persons of all ages, from infancy to old age, but most frequently in child- 
hood and youth. There are, however, some important deviations from this 
simple course. Occasionally a case is met with in which the inflammation 
extends to the membranes lining the antrums or the frontal sinuses or 
both, giving rise to more severe pain and heaviness both in the cheek bones 
and frontal region; more general febrile disturbance, with scanty and high 
colored urine. Such cases are more protracted, but pass through the 
same stages as those T have just described. When the discharge from the 
nostrils begins to be opaque or muco-purulent, there comes along with it, 
or sometimes a day or two later, a considerable quantity of a yellow, se- 
rous fluid, which makes the handkerchief stiff and sticky as if it had been 
wet with starch. This comes from one or more of the cavities just men- 
tioned, and is usually followed by much relief, or entire recovery. 

In other cases, however, the disease having reached the third or muco- 
purulent stage, further progress in the direction of resolution of the in- 
flammation ceases, and the case assumes a chronic form, in which condi- 
tion it is liable to remain for months and sometimes years. Another class 
of cases commences in ail respects like those of simple acute nasal catarrh, 
and in three or four days the irritation declines rapidly, but coincidently 
attacks in succession the membrane lining the fauces, pharynx, trachea, 
and bronchial tubes, causing soreness and tightness in the chest, with se- 
vere cough, and sometimes much dyspnoea. There is, also, still another 
class of cases in which the inflammation attacks simultaneously the whole 
mucous membrane of the air passages, accompanied by rigors, and fol- 
lowed by general irritative fever of considerable severity. These are 
cases of influenza, and- have been fully considered in the ninth lecture of the 
present course.* 

* See page 69 of present Vol. 



376 CHRONIC INFLAMMATION. 

Chronic Inflammation of the Membrane lining the Nasal Passages. — 
Some degree of chronic inflammation in the mucous membrane lining the 
nostrils and pharynx, usually called chronic catarrh, is one of the most com- 
mon diseases met with in all cold and variable climates. 

It is most generally the result of repeated acute attacks, but sometimes 
originates as a chronic form of disease without having been preceded by 
acute symptoms. It may occur at any period of life, although attacks are 
much more frequent in childhood and youth than later in life. The cases as 
met with in ordinary practice may be arranged in four groups. The first 
group includes all those cases characterized by a simple morbid sensitive- 
ness of the Schneiderian membrane, which, during warm dry weather gives 
the patient little or no trouble, but responds so readily to the influence of 
cold and damp air that the membrane becomes congested with the first 
recurrence of the wet and cold weather of autumn and remains so through 
the winter and spring. In most of these annually recurring cases, the pa- 
tient simply suffers from a feeling of fullness or obstruction in the nostrils, 
coupled with an abundant secretion of mucus, mostly of a water color and 
readily dislodged by blowing the nostrils freely. 

But any special or unusual exposure to currents of cold damp air gen - 
erally causes a temporary increase of tumefaction in the membrane with 
greater stenosis or obstruction to breathing through the nose, stopping of 
the tear ducts and a watery appearance of the eyes, which lasts from two 
to four days; and on its subsidence the secretion presents more of a muco- 
purulent appearance for two or three days and then returns to the state 
previously described. When the patient lies on the back, more or less of 
the secretion falls into the pharnyx and may be either swallowed, or 
hawked out by voluntary effort. In this class of cases there is usually little 
or no deterioration of the general health of the patient, but much annoy- 
ing inconvenience during the cold part of every year. 

The second group embraces such cases as involve chiefly the membrane 
lining the posterior part of the nostrils and covering the pharynx, consti- 
tuting anaso-pharyngeal disease of varying degrees of severity, but always 
annoying to the patient. The chief symptoms are a sense of fullness in 
the fauces with an excess of mucus, frequently of a thick viscid character, 
requiring much snuffing and hawking to dislodge it, especially in the 
morning, as it tends to accumulate in the posterior nasal fossa during 
sleep, and is capable of only an imperfect expulsion by blowing through 
the nostrils. In this class of cases there is little appearance of disease or 
discharge from the anterior part of the nostrils ; but the whole surface of 
the pharynx, the arch of the fauces, and the lining of the posterior nostrils 
as far as it can be seen, are red and tumefied from congestion of the ves- 
sels and more or less hyperplasia of the epithelium and connective tissue 
of the mucous membrane. In some cases the follicles are large, rounded, 
and smooth, looking like granulations. The discharge varies much in 
quantity and quality, being sometimes scanty and of a bluish tenacious 
character, and at others abundant and of a yellowish muco-purulent appear- 
ance. These cases, though often greatly aggravated by fresh exposures to 
the ordinary exciting causes in the changeable seasons of spring and 
autumn, seldom entirely disappear even in the warmest part of summer. 

The cases included in the third group, are in some degree a modification 
of those just described. The seat of the disease is the same, occupying 
chiefly the posterior part of the nostrils and pharynx ; but the inflamed 
membrane is darker red, dry, in some cases smooth, in others granular, and 
looking as though denuded of its epithelium. The secretion is scanty and 
of a gluey tenacious quality ; and usually dries up into crusts, like scabs, of 



SYMPTOMS. 377 

various sizes from the circumference of a small pea to that of a nickel half- 
dime. The larger masses accumulate mostly on the floor of the posterioi 
and middle part of the nostrils, but the smaller ones may be often seen ad- 
hering to the dry surface of the upper part of the pharynx. In many 
cases these dried masses or crusts are dislodged with much difficulty and 
often yield an unpleasant odcr. This group of cases is less influenced by 
atmospheric conditions or changes of the seasons, than either of those J 
have just previously described ; and are almost always associated with 
either a scrofulous or syphilitic constitutional condition. 

The fourth group includes those cases which are described by most 
authors and teachers under the name of ozena. In these, the inflamma- 
tion is located in the membrane covering the upper and lower turbinated 
bones, and lining the middle and anterior part of the nasal passages. It 
is met with mostly in childhood and youth, though sometimes also in the 
earlv part of aduit life. It may be limited to one nostril or it may involve 
both at the same time. The most prominent and characteristic symptoms 
are redness and tumefaction of the membrane, espesially where it covers 
the lower turbinated bone and lines the vomer, with an abundant muco- 
purulent discharge more or less offensive to the smell. In most of these 
cases the swelling of the membrane where it covers the lower turbinated 
bone presents a prominent rcunded or projecting surface somewhat like 
the appearance ot a polypoid growth, and either completely closes up or 
greatly narrows the passage through the nostril. In some children the 
discharge is not only abundant and muco-purulent but sanicus or irritating, 
causing excoriation of the upper lip which in some instances becomes 
covered with a thick honey-comb like scab, adding much to the bad looks 
as well as discomfort of the child. In other cases the inflamed mambrane 
in the nostrils becomes ulcerated, and even the turbinated bones more or 
less carious or necrosed. In some, the ulcerative process extends to the 
cartilage of the septum, destroying more or less of it and leaving a per- 
manent opening from one nostril into the other. In most cf the cases in 
this group, there is some degree of offensive odor to the discharge and to 
the breath that comes through the nostrils ; and in such as are accompa- 
nied by caries or necrosis of the bcnes the odor is almost intolerabl3. 

The cases belonging in this group, like those in the preceding one, 
occur almost exclusively in persons inheriting a syphilitic or scrofulous 
diathesis, or in those surrounded by such sanitary conditions as favor the 
development of the latter. In the naso-pharvngeal cases constituting the 
second and third groups, it often happens that the inflammation extends 
along the Eustachian tube to the middle ear causing sometimes pain, hut 
more generally only a sense of fullness with hissing, buzzing or other 
noises in the ear, and more or less impairment of hearing. In a few in- 
stances the inflammatory process extends into the lining of the antrums 
or frontal sinuses. In the former it may reach the root of some tooth that 
has penetrated the floor of the antrum, and cause it to become necrosed 
and the antrum filled with a sero-purulent fluid, thereby adding to the 
other symptoms much sense of fullness and severe pain in the region of 
the upper maxillary bone. 

A case of this kind came under my observation only a few months 
since, in which the extraction of the tooth was followed by the discharge 
of a large quantity of offensive purulent matter from the antrum. By 
rinsing out the antrum every day with anti-septic liquids, the suppurative 
process was arrested, the odor removed, and the patient recovered as far 
as the antrum was concerned; but he still suffers some from the chronic 
naso-pharyngeal inflammation. 



378 CHRONIC INFLAMMATION. 

Diagnosis. — I have given you all the important diagnostic symptoms in 
relating the clinical history of each group of cases, rendering it unnecessary 
to repeat them here. I wish to remind you, however, that the habitual 
use of tobacco, either by smoking or chewing, causes, in many persons, a 
congested and slightly swollen condition of the naso-pharyngeal mem- 
brane, sufficient to cause an unpleasant sense of fullness and a disposition 
to hawk and clear the throat with annoying frequency. If you regard 
these as cases of ordinary mild naso-pharyngeal inflammation, and attempt 
to treat them without prohibiting the further use of the tobacco, your 
treatment will be found to exert very little curative influence. 

Prognosis. — It is probable that uncomplicated cases of inflammation of 
the nostrils and pharynx cf a chronic character have never destroyed life. 

The prognosis, therefore, so far as relates to a continuance of life, is 
favorable in all grades of the disease. But though the disease does not 
directly endanger the loss of life, it is always troublesome to the patient; 
in some of its forms sufficiently severe to impair the general health; and 
very difficult of permanent cure, more especially while the patient remains 
in a cold and variable climate. 

Treatment. — There are very few of the more common diseases met with 
in the ordinary routine of medical practice, that have been treated more 
empirically, or have prompted the invention of a larger number of specific 
cures, than the various grades of inflammation of the mucous membrane 
of the nostrils and pharynx. Catarrh snuffs, nasal douches, sprays, and 
inhalations, have been invented and used with but little discrimination in 
all varieties and stages of the disease. Many of them have been useless, 
and some productive of positive harm instead of benefit. 

This is especially true of the too free and indiscriminate use of the nasal 
douche, by which inflammations and injuries have been caused in the 
middle ear, of more importance than the original catarrhal affection of the 
nostrils. I need hardly remind you, gentlemen, that there are no real 
specifics for the cure of any stage of inflammation of the mucous mem- 
branes, in the nostrils or elsewhere. And if you would give your patients 
suffering from any form of the annoying maladies now under consideration, 
the greatest possible degree of relief, you must in each case give due at- 
tention to the causes that may have induced the disease and may be still 
active in perpetuating it; to the extent and stage of advancement of the 
disease itself; and to the coincident cons itutional condition of the 
patient. There are very many cases of the acute and subacute forms of 
inflammation in the Schneiderian membrane, called coryza, which arise 
from temporary exposures to severe atmospheric changes by persons in 
other respects in good health, that get well in a few days without coming 
under the care of the physician. 

There are many other cases of the same class for which the physician is 
consulted, that need no other treatment than the restriction of the patient 
to a light plain diet with a limited use of liquids of any kind, and the 
taking of some laxative and diuretic medicine sufficient to gently increase 
the action of the bowels and kidneys. For this purpose a saturated solu- 
tion of the bi-tartrate of potassium in sweetened water, may be given in 
d ses of ten or fifteen cubic centimeters (fl. 3iiss or 3iv) three or four 
times during the day. Or if you are called early to a case of more than 
ordinary severity, just as the first stage of intense congestion of the mem- 
brane is beginning to give place to the copious thin discharge that usually 
follows, you may give the patient a full dose of the compound powder of 
opium and ipecacuanha, cover him up in bed for a sleep of six or eight hours, 
after which the bowels may be opened by a saline laxative, and if he takes 



TREATMENT. 379 

only light food and a limited amount of liquids, it will in a large propor- 
tion o( cases cut short the attack with but little nasal discharge. If any 
local applications are used in the first and second stages of such cases they 
should be simply of a soothing cr anodyne quality, and in the form of 
vapor. It is loubtful, however, whether in ordinary cases they do enough 
good to compensate for the trouble of using them. You may be some- 
times called to cases in which the stage of congestion and that of thin 
mucous secretion have both passed by, and you find the patient with a 
copious muco-purulent discharge, and considerable tumefaction of the 
nasal membrane; some dull frontal pains; slight acceleration of pulse and 
increase of temperature in the afternoon and evening, followed by some 
sweating in the latter part of the night; and a general feeling of weak- 
ness, with impairment of appetite. Such cases if neglected, are liable to 
be protracted in duration or end in the development of a chronic form of 
the disease. 

This result can be prevented in most cases, and the patient relieved in 
a few days, if you will give him from two to three decigrams (gr. iii to v) 
of sulphate of quinia each morning, noon, and evening; see that the 
bowels are simply kept regular by mild means; the diet plain but suf- 
ficiently nourishing; and the nostrils carefully washed out each morning 
and evening with some mild antiseptic and slightly astringent wash. I 
have used none that had a better effect than the solution of carbolic acid 
and sulphate of zinc, each six centigram (gr. i) to thirty cubic centi- 
meters (fl. |i) of water. The solution may be used with a suitable syringe, 
or if the patient can exercise good judgment, he may be instructed to 
snuff or draw it up gently from the palm of his hand, until he feels it pass 
into his pharynx from which he can readily hawk it forward, and spit it 
out. 

In the treatment of chronic naso pharyngeal inflammations, the benefit 
you confer upon your patients will depend very much upon the amount 
of attention you give to the removal of such co-existing functional and 
constitutional derangements as often exert much influence in perpetuating 
the local catarrhal affection, and on the skill with which you adjust the 
remedies addressed directly to the latter, to the particular grade of inflam- 
mation in each case. A large proportion of all the varieties of chronic 
cases have for their predisposing cause habitual failure or inefficiency of 
one or more of the excretory functions by which the products of tissue 
change and ; ther disturbing elements, are separated from the blood and 
eliminated from the system. This failure may be in the lungs and skin 
through want of regular active out door exercise, or in the bowels from 
habitual constipation; or in the failure of the kidneys to promptly in- 
crease the activity of their secretory action whenever the cutaneous 
surface is restricted by exposure to cold and dampness. If by any of 
these modes more or less of the products of tissue disintegration and 
waste are retained in the blood, they will not only greatly increase the 
tendency to develop disease in any of the more sensitive structures of the 
body, but their continuance through inattention of the physician, or 
neglect on the part of the patient, will render a cure of the local affection 
more difficult, and relapses more certain and persistent. 

Long and careful attention to this subject has satisfied me that a very 
large proportion of chronic catarrhal affections of the respiratory organs 
have their origin in the failure of some one or more of the excretory 
functions to which I have alluded; and especially in failure to maintain the 
proper sympathy or compensative adjustment of action between the skin 
and kidneys during the transition of the seasons, as well as during the 



3S0 CHRONIC CATARRH. 

more sudden transition from protracted periods of severe cold to a higher 
temperature. 

A very important part of the treatment of all chronic cases therefore 
cousists in carefully correcting whatever functional derangements exist. 
The judicious use of baths at such temperature as is most agreeable to the 
patient, perhaps twice per week, followed by thorough frictions with dry 
soft flannel; the wearing of warm flannel underclotnes; and daily active 
out-door exercise, constitute the most efficient means for establishing and 
maintaining the natural eliminations from the skin and lungs. Constipa- 
tion may be obviated and digestion improved by the use of certain tonics 
combined with just enough laxative medicine to secure a regular intesti- 
nal evacuation once in the twenty-four hours. For this purpose I have 
found nothing better suited to most cases, than the following combination: 

I£ Ferri Sulphatis 2.0 grams gr. xxx 

Extracti Hyoscyami 2.0 " fc * tw 

Pulveris Aloes 0.(5- " * x 

Pilulse Hydra rgvri 0.6 u " •* 

Extracti Nucis Vomicae 0.(3 " " " 

Mix. Divide into pills xxx; of which one may be taken before each 
meal-time, or before breakfast and dinner, as is found necessary to secure 
an easy, natural passage from the bowels once a day. If the case you 
have in hand is complicated with constitutional syphilis or scrofula, you 
must call to the aid of your patient all those hygienic and remedial 
measures that I recommended in lectures twenty- eight and thirty of the 
present course.* 

Local Treatment. — Remedies addressed directly to the diseased mem- 
brane, to be beneficial, must be carefully adjusted, both in their nature 
and modes of application, to the special conditions of each case. In the 
cases belonging to the first and second groups, as I have described them, 
the solution of carbolic acid and sulphate of zinc, used in the same man- 
ner as I mentioned when speaking of the treatment of the more advanced 
stage of acute cases, will be found one of the best that can be devised. 
In many of the same groups of cases, the frequent inhalation of the vapor 
of the oil of eucalyptus, has proved beneficial. This may be taken directly 
from the open mouth of a small vial containing eight or ten cubic centi- 
meters (3ii or 3iiss) of the oil. In cases of long standing, in which there 
is much thickening of the membrane and hypertrophy of the follicles, 
remedies capable of producing a degree of stimulating and alterative 
effect may constitute the best local applications. One that I have used in 
such cases with good effect is a solution of iodine three decigrams (gr. v) 
in fifteen cubic centimeters (fl. 3iv) of chloroform in a little vial with a 
glass stopper. One or two slow, full breaths of the vapor from the open 
mouth of the vial may be drawn through each nostril five or six times a 
day. The vial should be kept well stopped except while in actual use. 
In the cases I described as belonging to the third and fourth groups, one 
of the most important objects to be accomplished by local remedies is to 
maintain cleanliness and proper disinfection of the nasal pass ges. For 
this purpose the nostrils should be carefully but efficiently washed out, 
once or twice a day, with a solution of carbolic acid and sulphate of zinc 
in the proportion of six to thirteen centigrams (gr i to ii) of each, in 
thirty cubic centimeters (^i) of water. Solutions of permanganate of po- 

* See pages 258 and 286 of this VoL 



TREATMENT. 381 

tassium, benzoic acid, and chloride oi" sodium may be used for the same 
purpose and of the same strength. The best and safest instrument for 
using these solutions to cleanse the diseased surfaces is the post-nasal syr- 
inge. And even the use of this should not be intrusted to entirely un- 
skillful hands. Their use with the ordinary fountain nasal douche is so 
liable to be followed by pains and inflammation in the Eustachian tubes, 
middle ear, and antrums, that I have deemed it better to prohibit this 
method altogether. In several cases I have found free cleansing of the 
nasal passages with the syringe once in three days, and the use, each 
morning and evening during the intervening days, of inhalations of a 
mixture of ca bolic acid two grams (gr. xxx) oil of Scotch pine four 
cubic centimeters, (fl. 3i) and camphorated tincture of opium sixty cubic 
centimeters (fl. §ii) in the following manner to keep the parts in 
good order: Put four cubic centimeters of the mixture into half a pint of 
hot water in an ordinary inhaling bottle, and instruct the patient to take 
in a full inspiration of the vapor from the mouth-piece and force it back 
through the nostrils. This process may be continued from three to five 
minutes two or three times a day. If proper attention is given to such 
internal treatment as the general health and special constitutional condi- 
tion of the patients require, on the principles I have indicated, with the 
aid of the local applications I have now mentioned, almost all the cases of 
chronic nasal and naso-pharyngeal inflammations will be greatly im- 
proved and many of them will be cured. But those cases which have be 
come complicated with extensive ulceration of the membrane and either 
caries or necrosis of the turbinated or other bony or cartilaginous struct- 
ures, will make no marked progress toward recovery until the diseased 
portions of bone are removed either spontaneously, by exfoliation, or by 
surgical interference. When foul and ill-conditioned ulcerated places are 
so located that they can be reached with the aid of the rhinoscope and 
other instruments, much improvement may be produced by applying to 
the ulcerated surface daily a small quantity of a powder composed of 
finely pulverized white sugar two parts and iodoform one part. Having 
given you the results of my own observations and clinical experience in 
the management of the various grades of the disease under consideration, 
I will detain you for only one further remark, namely, that a very large 
proportion of patients suffering from chronic naso-pharyngeal inflamma- 
tion can be permanently relieved only by changing their residence from a 
cold, variable climate, to one mild and dry; and at the same time abstain- 
ing altogether from the use of alcoholic drinks and tobacco. 



LECTURE XL 



Inflammations of the Larynx an^i Trachea— Croup ; Their Varieties, Causes, Anatomical Char- 
acteristics, Symptoms, Diagnosis, Prognosis and Treatment. 

GENTLEMEN: Although the larynx and trachea are anatomically 
distinct divisions of the respiratory passage, and the mucous mem- 
brane in each capable of being ii flamed to some extent without extending 
into the other, yet in all the more serious attacks the membrane in both sec- 
tions is involved, constituting a true laryngo-tracheitis. Practically, there* 



3S2 LAKYNGOTRACHErTIS. 

fore, they constitute but one section in their relations to the inflammatory 
affections, and I shall so regard them during the remainder of the present 
lecture. 

Varieties. — Laryngitis, or laryngo-tracheitis, may be met with in all de- 
grees of intensity, from simple hyperemia, with increased irritability of the 
texture, to the most intense plastic or pseudo-membranous inflammation. 
It may be acute, running its course in a few days, or it may be so chronic as 
to continue as many months, or even years. Anatomically, the inflammatory 
process may be limited to the epithelial or free surface of the membrane, 
causing hyperasmia, with increased mucous exudation; or it may extend to 
the sub-mucous tissue, causing inflammatory exudations beneath the lining 
membrane as well as upon its surface and consequently greater tumefaction 
of the parts; or it may be of such grade as to cause the exudations upon 
the surface to be highly plastic, and to undergo rapid organization into a 
layer of false membrane closely adherent to the inflamed surface. On the 
other hand, cases more rarely occur involving the sub-mucous tissue, and 
causing a serous exudation by which the parts are rendered cedematous and 
much tumefied. Hence, for convenience of description, the cases liable to 
be seen in general practice may be arranged into four groups, namely, the 
mucous or superficial laryngitis; the sub-mucous; the pseudo-membranous; 
and the cedematous. Either of these varieties may be acute, subacute or 
chronic, in their grade and rate of progress. 

Causes. — The causes of the different varieties of laryngitis are the same 
as I mentioned, more in detail, when discussing the etiology of inflamma- 
tions of the mucous membrane of the respiratory passages generally, in 
the preceding lecture. The first or superficial variety is of frequent oc- 
currence at all periods of life; and may be produced by exposures to cold 
and damp air especially when accompanied by high winds; by excessive 
use of the voice; and as a result of eruptive fevers and tuberculosis. The 
second and third varieties occur much more frequently in childhood; while 
the fourth, or cedematous laryngitis is mostly limited to the adult period 
of life. 

Pathological Anatomy. — The anatomical changes which take place 
during the progress of inflammation in the membrane lining the larynx 
and trachea do not differ essentially from those which characterize the 
same grade of inflammatory action in other parts of the respiratory mu- 
cous membrane. In the simple superficial inflammation there is intense 
redness from congestion of blood in the vessels and slight tumefaction, 
with temporary dryness, followed speedily, however, by an increased secre- 
tion of mucus, at first transparent and tenacious, but subsequently 
changing to a white, opaque, or slightly yellowish appearance, and con- 
taining more or less epithelium and pus corpuscles. If the inflammation 
is more severe, extending to the sub-mucous tissue, there is added to 
these superficial changes, more or less exudation of serum with white and 
red blood corpuscles, into the texture of the membrane and into the con- 
nective tissue beneath it, adding much to the tumefaction of the parts. 
In the middle and later stages of the case pus cells become freely min- 
gled with the other exudative materials, and in some instances the base- 
ment membrane becomes denuded of its epithelium in patches, giving it the 
appearance of abrasions or slight ulcerations. In the third, or pseudo- 
membranous grade of the inflammation you find all the changes I have 
mentioned as belonging to the simple mucous and sub-mucous varieties, 
with the important addition of a large proportion of fibrin and lymphoid 
cells in the exudative materials. 

The addition of these plastic elements causes the exudative materials 



SYMPTOMS. 383 

upon the surface of the membrane to rapidly solidify or organize into a 
firm, white, adherent layer of false membrane; generally thickest and 
most adherent over the vocil cords and the rima glottis, but often extend- 
ing upward over the lower part of the pharynx and downward through 
the whole extent of the larynx and trachea to the larger bronchi. The 
rapid exudation upon the surface of the membrane in this class of cases 
detaches much of the epithelium, and hence on close examination you find 
in many places the layer of false membrane resting directly on the sur- 
face of the basement membrane, but not permeating it, as is the case in 
the membranous formations of true diphtheria. More or less of epithelial 
and pus cells, and red blood corpuscles may be seen in the meshes of the 
fibrillated fibrin constituting the basis of the false membrane. As the 
disease advances beyond the first stage, the proportion of pus cells and 
necrosed epithelium cells increase, with an increased exudation of mucus, 
lessening the tenacity of the plastic or organized false membrane and 
causing it to be detached in shreds or patches, and sometimes in whole 
tubes of considerable length. At first, new layers of false membrane form 
on those surfaces from which the first layer had been detached, but in 
acute cases this tendency ceases after the fourth or fifth day, and the in- 
flammatory process rapidly declines. In the fourth group of cases, called 
cedematous laryngitis, a large part of the exudation is into and beneath 
the membrane, and is composed of serum or the watery element of the 
blood. Consequently it is a true oedema of the parts, especially over the 
vocal cords and at the base of the epiglottis. Occasionally colonies of 
bacteria have been found in the meshes of the pseudo-membranous forma- 
tion, but with no uniformity, and no evidence that they exert any causa- 
tive influence. 

Symptoms. — The circumstances connected with the natural structure of 
the larynx, exert much influence over the character of the symptoms which 
accompanv inflamm ition of its lining membrane, as well as over the results 
of such inflammation. These are, the narrowness of the rima glottidis, or 
opening into the larynx; the firm, unyielding condition of its walls; and the 
special sensitiveness of the nerves of the part. The narrowness of the en- 
trance from above into the larynx is such, that a very moderate swelling of 
the lining membrane is capable of creating marked dyspnoea or obstruction 
to the breathing, while the firmness of the laryngeal walls prevents disten- 
sion, and thereby causes tha whole of the congestion and tumefaction to 
crowd inward, still further diminishing the space for the ingress and egress 
of air in breathing. The sensitiveness of the nerves and their relation to 
the muscles of the larynx, and, in some degree, to the muscles of respiration 
generally, cause the presence of inflammatory action to readily excite severe 
spasmodic contractions in the muscles and to impart to the cough a spas- 
modic and paroxysmal quality, both distressing and, in some cases, danger- 
ous to the patient. The milder cases of superficial inflammation of the lar- 
ynx in the adult are characterized at first by a sense of fullness, soreness 
and heat in the larynx; hoarseness or roughness of voice; a dry and rough 
or ringing cough; and slight sense of difficulty in breathing. 

The general febriie symptoms in such cases are very slight, and in some, 
absent altogether. In the same class of cases in children under five years 
of age, there is more uniformly sufficient fever to cause a little accel- 
eration of pulse, a rise of one or two degrees of temperature, and the ad- 
dition of more distinct paroxysms of dyspnoea from constriction of the lar- 
ynx, with a more spasmodic quality of cough. After the first twenty-four 
hours, the increased secretion or exudation of mucus upon the surface of the 
inflamed membrane renders the cough less dry and ringing, and causes some 



384 LARYNGO-TKACHEITIS. 

coarse moist rales as the air passes through the larynx. In most cases during 
the third day, whatever of general febrile symptoms had existed, disappear; 
the cough is less spasmodic and accompanied by more free mucous expecto- 
ration; and the paroxysms of dyspnoea less frequent. During the next two 
or three days the hoarseness and all other symptoms of disease disappear; 
making the whole duration of the laryngeal symptoms from five to seven 
days. In the second or sub-mucous grade of inflammation, the symptoms 
are the same in kind but much more severe. There is usually some chilli- 
ness at the beginning, followed by more decided fever; more frequency and 
fullness of pulse* more sense of constriction in the larynx; more frequent 
and severe paroxysms of dyspnoea with dry whistling sounds in the larynx 
at first, subsequently replaced by coarse mucous rattles; a more severe spas- 
modic or suffocating cough with increased hoarseness and, in some cases, en- 
tire suppression of voice. In the more severe examples of this class during 
the second and third days, the opening of the larvnx becomes so narrowed 
by the exudation into and beneath the membrane, and the constant accumu- 
lation of mucus upon its surface, that the difficulty of breathing is con- 
stant and noisy, with paroxysms of coughing that seem to threaten the act- 
ual suffocation of the patient. The mucus is tenacious and difficult to dis- 
lodge, especially in young children, and yet accumulates so rapidly as to 
compel frequent and tiresome efforts at coughing, during some of which 
the stomach turns and brings an effort to vomit, by which considerable quan- 
tities of mucus are expelled from the larvnx and throat, with much temporary 
relief to the little sufferer. But the constant obstruction to the ingress and 
egress of air, coupled with the frequent struggles in the paroxysms of cough- 
ing, soon begin seriously to impair the oxygenation and decarbonization 
of the blood and to exhaust the strength of the patient. The flush of the 
face gives place to a bloated and pale appearance with a leaden or purplish 
hue of the prolabia; the extremities become cool and bluish; pulse, frequent 
and small; the mind dull, with inclination to lie with the head thrown a lit- 
tle back to straighten the larynx; the eyelids only partly closed, and the 
larynx moving up and down with every inspiration and expiration, accom- 
panied by laryngotracheal rales loud enough to be heard over the whole 
room. This, to the patient, half unconscious quiet, is disturbed every five 
to fifteen minutes by sudden and severe paroxysms of coughing, and strug- 
gling to clear away the laryngeal obstruction. 

In the worst cases of this class, at this stage of their progress, the strength 
of the patient fails rapidly; the extremities become cold; pulse a mere 
thread; discharges of urine and faeces involuntary; the face more pale, eye- 
balls turned upward, with the lids half-closed; the mind too dull to be 
aroused; the head further back; the larynx still more strongly moved up 
and down with the efforts to force air through it; until, at length, the chin 
drops and, with a few more gasps for breath, the struggle for life ceases. 
Such, gentlemen, is an outline of the phenomena accompanying the progress 
of a fatal case of sub-mucous laryno-itis, or croup; and you will only need 
to witness it once to have its vivid and distressing features indelibly fixed 
in your minds. When death occurs in this class of cases, it is usually be- 
tween the third and fifth days from the beginning of the attack. But in 
most of this class of cases, the tumefaction of the membrane and the ac- 
cumulated inflamatory products are not sufficient to fatally interfere with 
the respiratory function, and after the second day, the sub-mucons exuda- 
tion begins to diminish, the mucus on the surface becomes more abundant, 
less tenacious and a little opaque; the paroxysms of coughing are less suf- 
focating and dislodge the mucus more readily, and the general febrile 
symptoms also begin to abate. The crisis of the inflammatory process 



SYMPTOMS. 385 

having; passed, the symptoms continue to improve from day to day, and 
leave the patient convalescent in from five to nine days from the com- 
mencement of the symptoms. 

In the pseudo-membranous class of cases, called by some writers true 
croup, the essential symptoms and progress correspond closely with those 
of the most severe cases belonging to the sub mucous class as just described. 
The attacks are limited mostly to children under ten years of age. They 
differ from the severe cases just fully described chiefly in three particulars. 
(a) The stage during which the laryngeal sounds remain dry and whistling, 
is more marked and protracted, with apparently greater constriction of the 
tube, (b) The voice is more hoarse or more completely suppressed, and 
the paroxysms of coughing are characterized at first by greater spasmodic 
violence and loud stridulous sounds, and subsequently by a muffling or 
suppression of the sounds, corresponding with the suppression of the voice, 
(c) There appears early upon the surface of the rima glottidis, epiglottis, and 
sometimes up over the lower part of the pharynx a layer of white, fibrin- 
ous and plastic exudation which constitutes the pseudo-membrane, that has 
given the name of pseudo-membranous laryngitis or membranous croup to 
this variety of the disease. At the same time the secretion of mucus is 
much more scanty than in the other varieties, and when the patient begins 
to dislodge and expectorate some in his paroxysms of coughing, close ex- 
amination will generally discover in it small shreds of the solidified or fibril- 
lated fibrin torn from the layer of adherent pseudo-membrane. If the 
patient does not suffer so rapid an accumulation of the inflammatory prod- 
ucts as to induce death by suffocation within thirty-six hours, the mucous 
secretion increases, adding more of the rattling moist sounds to the breath- 
ing, and in the severer paroxysms of coughing dislodging larger pieces of 
the false membrane. From this stage of progress, in the milder examples 
of this class, the mucous secretion continues to increase and becomes more 
opaque; the false membrane gradually loosens and is dislodged more and 
more freely in shreds and patches by the violent paroxysms of coughing, 
aided sometimes hj vomiting; and in some rare instances, the whole mem- 
brane is expelled at once, presenting when distended in water a complete 
representation of the interior of the larynx. With the breaking up and ex- 
pulsion of the false membrane, all the essential symptoms improve and the 
patient reaches the stage of convalescence in from one to two weeks. In 
a large proportion of this class of cases, however, the plastic exudations 
continue to accumulate, the laryngeal obstruction becomes hourly more se- 
vere until some time between the second and fifth days death ensues, pre- 
ceded and accompanied by essentially the same symptoms I have already 
described. 

The fourth group of cases which includes those affected with true oedema 
of the glottis, occurs almost exclusively in adults, in connection with a debil- 
itated, depraved or anaemic condition of the system caused by some prior dis- 
ease. It has occurred during the convalescing stage of typhoid and typhus 
fevers. Only a few months since a fatal case of this kind occurred in the 
Mercy Hospital, in an adult male, who had begun to convalesce from a se- 
vere attack of typhoid fever complicated with severe broncho-pneumonia. 
The attacks generally supervene suddenly and the serous exudation or in- 
filtration accumulates rapidly in the areolar or connective tissue at the base 
of the epiglottis and above the vocal cords, quickly suppressing the voice 
and causing such a degree of tumefaction as to obstruct the free ingress but 
not the egress of air, and giving rise to laryngeal dyspnoea, suffocating 
paroxysms of coughing, imperfect oxygenation and decarbonization of the 

25 



386 CHEONIC LAKYNGITIS. 

blood, and in most cases death from apncea, or exclusion of air from the 
lunjrs, in from twelve to thirtv-six hours. A few of the less severe cases 
recover. 

Chronic Laryngo- Tracheitis — Chronic inflammation may exist in any 
part of the lining membrane of the larynx and trachea, and maybe either 
the sequel of an acute attack or may have originated de novo. A very lanre 
proportion of the cases met with in practice are the result of tubercular de- 
posits in the follicles of the laryngeal membrane, and are uniformly assoc : ated 
with more or less tubercular disease in the lungs. I have met with no ex- 
ceptions to this rule. Another, though less numerous class of cases, are the 
result of constitutional syphilis. Chronic laryngitis not dependent on either 
tuberculosis or syphilis is rarely met with in ordinary practice. 

Symptoms. — The two most prominent and characteristic symptoms are 
alterations of the voice and cough. The first may be simply hoarse, rough 
or squeaking, presenting different degrees of dysphonia, or it may be sup- 
pressed, aphonia. The latter, which is always present in some degree but 
varying much in frequency and severity, presents the same characteristics 
as the voice, being in some cases simply harsh or rough, in others ringing 
or stridulous, and in still other cases so muffled as to be without vibratory 
sounds. In cases not complicated by either tuberculosis or syphilis, there 
is usually only a moderate sense of uneasiness or slight soreness in the lar- 
ynx, but rather a tickling or sense of something present that ought to be 
cleared away, prompting the patient to cough or hawk, as if to clear the 
throat; yet in such cases, there is only a scanty secretion of mucus, which 
presents a white and rather frothy appearance when expectorated. On 
the other hand, when the case is complicated with tubercu'ar deposits, the 
•cough generally becomes much more troublesome and severe, harassing 
the patient much, especially during the last part of the night and early in 
the morning, accompanied in the early stage by the expectoration of a vis- 
cid water-colored mucus, which gradually becomes opaque, and finally 
purulent. 

There is in these cases also much greater sense of soreness and constric- 
tion, with frequent pains in the larynx and trachea; and in the later stages 
of their progress, some general fever every afternoon and evening, disappear- 
ing with some sweating in the last part of the night, leaving the patient 
cool, pale, and weak in the morning, when the paroxysms of coughing are 
most severe and strangulating, and often accompanied by efforts to vomit. 
There is also a pretty constant loss of flesh and strength until the patient 
presents all the symptoms of the advanced stage of pulmonary phthisis, 
including copious purulent expectoration, hectic fever, night sweats and 
the physical signs of suppurative cavities in the upper part of one or both 
lungs. And yet, owing to the constant annoying sensations, such as tick- 
ling, soreness and sense of constriction in the larynx, which appear to be 
the immediate cause of the cough, the patient will persist in attributing 
all his sickness to the affection of the larynx, and often firmly deny that 
there is anything the matter with his lungs or parts within the chest. And 
[ have met with some cases in which the attending physician had allowed 
himself to be so far misled by the positive assertions of the patient as to 
overlook the coincident pulmonary lesions entirely, until within a few weeks 
}f the fatal termination. Let me caution you, gentlemen, against the com- 
mittal of any such blunders. In every case of chronic laryngitis it will 
be your duty to examine the chest carefully and repeatedly for the physical 
signs of pulmonary tuberculosis, without regard to the sensations or opin- 
ions of the patient. When chronic laryngitis arises from syphilitic influ- 
ence, the local symptoms differ from those of the tuberculous variety, 



PATHOLOGICAL ANATOMY. 387 

chiefly in the greater degree of pain and soreness, more distinct tenderness 
to pressure and sometimes slight swelling over some of the cartilages, and 
more rapid ulceration particularly of the epiglottis and parts above the vo- 
cal cords. When the epiglottis and lower posterior part of the rima glot- 
tidis is the seat of ulceration, whether connected with syphilis or tubercu- 
losis, the swallowing of food becomes acutely painful; and when the epi- 
glottis is largely destroyed, as happens in some cases, the taking of food 
is not only painful, but it so frequently enters the larynx, causing the most 
violent coughing and choking, that the patient can not be persuaded to take 
sufficient to prevent ultimate starvation. 

Pathological Anatomy. — In simple uncomplicated chronic inflammation 
of the larynx and trachea, instead of intense redness as in the acute grade 
of the disease, the mucous membrane has a grayish color, and more or 
less of a granular appearance from hypertrophy of the mucous follicles, 
and is partially covered with a layer of mucus or muco-purulent matter. 
The epithelium covering the vocal cords is generally thickened and more 
opaque; and in most of the cases the whole inflamed part of the mem- 
brane is thicker and harder than natural from hyperplasia or increased 
growth of the connective tissue elements. Ulcerations are rarely seen in 
this class of cases; but in a few instances some of the mucous glands 
have become so much enlarged as to project like papillomatous growths 
from the surface of the membrane. A few cases have been reported in 
which the laryngeal membrane was atrophied or thinner than natural. In 
cases arising from primary tubercular deposits, ulcerations constitute a 
prominent part of the pathological changes, in addition to those I have 
mentioned. They are more frequently located at or near the posterior 
commissure of the vocal cords, but may be seen in different cases in all 
parts of the membrane. 

You may find in one case but a single ulcer, and in another several, 
varying much in their size and progress. In the syphilitic cases, ulcera- 
tion commences early and in most cases extends from the pharynx to the 
epiglottis first, and then downward into the glottis and over the vocal 
cords. In some rare instances the inflammation and suppuration extend 
to one or more of the cartilages, forming abscesses that may break, either 
into the larynx adding to the necessity for frequent coughing, and expec- 
toration of pus generally more or less offensive to the smell; or externally 
through the integuments, where it will result in a protracted fistulous dis- 
charge, or extend into an open indolent ulcer; and in some instances in- 
volving necrosis of the cartilage itself. 

Diagnosis. — The diagnosis of all grades of inflammation affecting the 
mucous membrane of the larynx, is not difficult. The interference with 
the function of the vocal cords and the access of air to the lungs, necessi- 
tates such changes in the voice, the cough, the mucous secretion, and the 
passage of air, as point directly to the seat of disease. And it only re- 
quires a reasonable degree of attention on the part of the practitioner to 
distinguish between the persistent and progressive symptoms of inflam- 
mation, and the more transient and changeable phenomena of mere nerv- 
ous and functional disturbances. And in cases involving any doubts a 
careful examination with the laryngoscope should dispel them. 

Prognosis. — On account of the narrowness of the opening into the larynx 
and the small amount of swelling in the parts required to close or so ob- 
struct it as to deprive the lungs of sufficient air for the purposes of life, all 
of the more severe grades of inflammation affecting its interior membrane 
are highly dangerous and result in a large ratio of mortality. The simple 
mucous or superficial grade of laryngitis seldom terminates fatally, either 



388 LARYXGO-TRACHEITIS. 

in childhood or adult life. The sub-mucous variety is necessarily accom- 
panied by greater tumefaction, and consequently more danger, especially 
in young children ; yet a large majority of this class recover. 

But the pseudo-membranous cases, which occur chiefly in childhood, 
result in a much higher ratio of mortality; and the same is true of the 
oedematous form of the disease as it occurs in adults. It is probable that 
considerably more than one half of ail the cases of either of these varie- 
ties terminate fatally. The simple non-specific form of chronic laryngitis 
seldom causes sufficient swelling of the inflamed structures to obstruct the 
ingress or egress of air in such degree as to endanger the life of the pa- 
tient; although it may give him great annoyance for an indefinite number 
of years. Chronic cases, dependent on constitutional syphilis, are gener- 
ally curable by appropriate treatment, unless the cartilages have become 
necrosed with extensive suppuration; or so large a part of the epiglottis, 
rima glottidis, and vocal cords have been destroyed by ulceration as to 
prevent the patient from taking sufficient food. The scrofulous and tu- 
berculous cases of chronic laryngitis very seldom recover, but the ulti- 
mately fatal termination is induced more by the progress of the disease in 
the lungs, than in that affecting the larynx or trachea. 

Treatment. — The treatment of all forms of acute and sub-acute laryn- 
gitis embrace the accomplishment of three objects, namely, to lessen the 
morbid sensitiveness or irritability of the inflamed structures; to lessen 
the vascular fullness or congestion in the early stages and thereby limit the 
amount of either sub-mucous or plastic exudation; and in the later stage 
to hasten the disintegration and removal of such exudation as may have 
occurred. 

In the mild or superficial form of the disease, neither of the pathological 
conditions on which these indications are founded, are sufficiently devel- 
oped to endanger the life of the patient or to require very active remedial 
measures for relief. Confinement to the house, or protection from further 
exposures to cold or severe currents of air, the inhalation of some mild 
anodyne vapor, or the taking of a mild anodyne expectorant, is usually 
sufficient to cause the disappearance of the symptoms in a few days. The 
following is a prescription I have long used in this class of cases with 
benefit: 

]J Syrupi Scillae Compositi 45.0 c. c. Jiss 

Syrupi Ipecacuanhas 15.0 " |ss 

Tinctura3 Opii Camphoratas 60.0 " |ii 

Mix. To an adult, I give four cubic centimeters (fl. 3i) in a little 
water every three, four, or six hours. To children less in proportion to 
their age. If the skin is quite hot and dr}* and the urine scanty I give from 
six to twenty centigrams (gr. i to ii;) of calomel, and follow it with a 
saline laxative sufficient to procure two or three intestinal evacuations. 

These measures, with a continuance of moderate doses of the anodyne 
expectorant mixture for three or four days, usually constitute all the treat- 
ment needed in such cases. In the second group of cases, in which the 
inflammation involves the membrane more deeply, and if not checked in 
its incipiency, causes the accumulation of exudative material both in the 
texture of the membrane and in the sub-mucous areolar structure, the 
tumefaction or swelling is sufficient to cause more or less danger from its 
obstruction to the ingress and egress of air. Consequently this class of 
cases need prompt and efficient treatment. As this form of the disease is 
met with most frequently in children, if I am called early to a child be- 
tween three and. five years of age, presenting the symptoms 1 have men- 



TREATMENT. 389 

tinned as characterizing well marked cases of sub-mucous laryngitis, I 
order a powder containing fifteen to twenty centigrams (gr. iiss to iii) of 
the sub-sulphate of mercury (turpeth mineral) to be given at once, which 
seldom fails to produce free vomiting in from fifteen to forty-five minutes. 
Tl* it fails to do this I have the dose repeated at the end of forty-five minutes. 
Directly after the vomiting I commence giving the same anodyne expec- 
torant mixture, the formula for which I gave you only a few minutes since, 
in doses of from one to two cubic centimeters (min. xv to xxx) every two 
or three hours. If the bowels are not already loose, I give, also, thirteen 
centigrams each of calomel and bicarbonate of sodium, in one dose, which 
usually induces a moderately free evacuation from the bowels in three or 
four hours. 

These measures are usually followed by much relief to the breathing; 
more free secretion from the mucous membrane of the air passage; and 
less fever. If such relief continues for twenty-four or thirty-six hours, 
the crisis of the disease will have passed, and the case will require only 
the moderate continuance of the anodyne expectorant mixture for two or 
three days or until convalescence is fully established. But in many cases 
the relief following the first vomiting proves only temporary, and in from 
three to six hours the paroxysms of dyspnoea and coughing again become 
severe. When this is the case I promptly repeat the emetic dose of the 
sub sulphate of mercury, after the action of which the same internal rem- 
edies are continued as before, while externally I keep the front part of the 
neck covered with cloths wet in an infusion of hops or aconite leaves hold- 
ing in solution muriate of ammonia. In the more sanguine and robust 
class of children, I have applied leeches in sufficient number to cause a 
pretty free local bleeding, in the early stage of the disease, with the most 
decided benefit. You may occasionally meet with a case in which after 
the acute stage has passed by, there remains a harsh croupy cough, with 
sufficient tightness in the laiynx to indicate that the tumefaction of the 
mucous membrane is subsiding very slowly. If you do, the substitution 
of the same quantity of the tincture of sanguinaria in place of the syrup 
of ipecacuanha in the formula I have given you, and the addition to the 
same of ten grams (3iiss) of the iodide of potassium, will add much to its 
alterative properties and render it more efficient in promoting the removal 
of the remaining inflammatory products. In locations where malarious or 
periodical fevers prevail, sulphate of quinia, in doses of thirteen centi- 
grams (gr. ii) may be given between the doses of the expectorant mixture, 
to a child five years of age, with much benefit. 

In the pseudo-membranous variety of laryngitis, the treatment must be 
guided by the same principles as in the sub-mucous variety, but pursued 
more energetically, especially in the early stage. x\ prompt local bleeding 
by leeches, and free vomiting by the sub-sulphate of mercury should com- 
mence the treatment, and be followed by a cathartic dose of calomel and 
bicarbonate of sodium. Then the anodyne expectorant mixture already 
mentioned should be given alternately with alterative doses of the calomel 
and nitrate of potassium, from one to two hours apart. The emetic should 
be repeated in from three to six hours according to the degree of dyspnoea 
and whistling sounds in the larynx. If possible, the spray of dilute lactic 
acid, one cubic centimeter (min. xv) to forty-five cubic centimeters 
(fl. 5iss) of water, should be thrown into the pharynx freely every hour. If, 
under the combined influence of these remedies, the progress ot the disease 
appears checked, as indicated by less dyspnoea, more free expectoration of 
opaque mucous with numerous shreds of the pseudo-membrane, less 
spasmodic violence in the paroxysms of coughing, anil less general fever, 



390 LARYNGO-TRACHEITIS. 

the further use of emetics may be dispensed with, and the other remedies 
given at longer intervals. If the improvement continues after the first 
thirty-six or forty-eight hours, the calomel and nitrate of potassium rnav 
be discontinued, and moderate doses of sulphate of quinia given in their 
place. If instead of improvement, h wever, you find your patient on the 
second or third day showing signs of exhaustion, such as paleness of the 
face with a leaden hue of the prolabia; cool extremities, feeble pulse, 
more constant difficulty of breathing, and drowsiness between the parox- 
ysms of coughing, you had better omit both the anodyne expectorant 
mixture and the powders of nitrate of potassium and calomel, and give in- 
stead, a solution of lactate of iron in water alternately with moderate 
doses of the sulphate of quinia. 

To a child live years of age you can give from three to six centigrams 
(gr. ss to i) of the lactate of iron in solution every two or three hours, 
and from six to nine centigrams (gr. i to iss) of quinine between. Once 
or twice in the twenty-four hours, if the larynx becomes very much ob- 
structed by the exudation, a quick free vomiting may be induced by giving 
a full dose of powdered alum and ipecac, with the hope that much of the 
accumulation has become loosened and may be expelled during the effort 
of vomiting. It is true that most of the patients who reach the condition 
I have described will die. But none should be given up or abandoned 
until life has actually ceased, for I have seen several recover from a con- 
dition apparently hopeless. In the first stage of these severe cases but 
little attention need be paid to nourishment; but in the more advanced 
stage when the strength begins to fail, milk, beef tea, etc., should be 
given as regularly as the doses of medicine. In cases where the relief is 
partial, and there appears to be a tendency to run a protracted course, one or 
more small blisters in the vicinity of the larynx may do good. Through- 
out the whole course of the disease the temperature of the air in the 
room should be kept uniform as possible varying from 20° to 21° C. 
(68° to 70° F.), and rather moist. Some direct the air of the room to be 
kept at a much higher temperature and constantly saturated with aqueous 
vapor. But my own observations have led me to think such an atmosphere 
strongly calculated to lessen the exhalations from the lungs, and to in- 
crease the danger of early and excessive prostration. A large number of 
other remedies, besides those I have mentioned, have been strongly rec- 
ommended by different writers, most of which I have either tried or had 
ample opportunities of seeing tried by others. In the list of emetics you 
may find lobelia inflata, tartar emetic, alum, sulphate of zinc, sulphate of 
copper, ipecacuanha, and apomorphia; while as local remedies you will 
find the inhalation of the vapor of water containing freshly slacked lime, 
the spray of chlorate of potassium, iodide of potassium, nitrate potassium 
and benzoate of sodium, with and without the addition of belladonna or 
conium to the solution; and the direct application of strong solutions of 
nitrate of silver, iodine, and tincture of chloride of iron. But from 
none of them have I seen as good results as from the course 1 have directly 
recommended to you. As the great points to be gained in the manage- 
ment of the pseudo-membranous form of the disease, are to lessen the 
amount and plasticity of the exudative material, and to hasten the loosen- 
ing or disintegration of such plastic material as does accumulate on the 
surface of the inflamed membrane, it will be difficult to find any agents 
better calculated to produce these effects than the local bleeding aided by 
the relaxing and expulsive effects of the sub-sulphate in emetic doses, fol- 
lowed by the alterant and aplastic influence of the calomel and sodium or 
potassium salts, with such adjuncts as I have already named. In applying 



TRACHEOTOMY. 391 

leeches to young children care should be exercised that the number be ad- 
justed to the age and condition of the patient. In infants of one year or 
less not more than two leeches should be applied at once, and the bleeding 
may be promoted from the bites by applications of warm wet cloths, or 
stopped by styptic applications according as the effects produced may in- 
dicate. At the time I commenced the practice of medicine much reliance 
was placed upon the emetic and sedative effects of tartar emetic in the 
treatment of all grades of laryngitis or croup. But as early as 1840, or 
near that time, my attention was directed to the use of the yellow sub- 
sulphate of mercury as an emetic in this form of disease, by the report of 
several cases treated successfully, in which it was used by Dr. Hubbard, 
of New Hampshire. And from that time to the present I have certainly 
obtained better results from its use as an emetic, than from any other rem- 
edv given for the same purpose. 

Tracheotomy. — When, in the more severe class of cases of laryngitis, 
ordinary methods of treatment fail to make any favorable impression on 
the progress of the disease, the question whether the operation of trache- 
otomy ought to be resorted to, always comes up for consideration. Most 
of the writers on practical medicine recommend a resort to it in such cases 
as persist in the increase of dyspnoea notwithstanding the use of the most 
active internal and local remedies, and caution the practitioner against 
delaying its employment until the patient is too much exhausted. This 
subject was very fully and ably considered by Dr. H. Z. Gill of Jersey- 
ville, Illinois, in two reports to the Illinois State Medical Society, the first 
in 1879, and the other in 1880.* His tables include 129 cases in which 
the operation was performed, resulting in 93 deaths and 36 recoveries. A 
majority of the patients operated on were laboring under well marked 
diphtheria, the inflammation having invaded the larynx. The remainder 
of the cases are designated in the tables either as croup, true croup, or 
pseudo-membranous croup. But no attempt is made by the writer to 
establish a clear line of distinction between these several grades of 
disease. As the operation was performed in some of the cases at an early 
period, while the patient's strength was good, it is impossible to know 
whether they would not have lived if the operation had not been performed. 
In all the cases of true pseudo-membranous laryngitis coming under my 
own observation, in which the operation was performed by some one of 
our best surgeons, death has been the result. Not directly on the operat- 
ing table, but in from six to seventy-two hours after; and pretty uniformly 
from the development of inflammation and exudation in the trachea and 
larger bronchi. 

It is well known that cases occur in which patients recover from this 
variety of disease after their condition appears to be hopeless. Therefore, the 
question whether the operation for tracheotomy shall be performed in any 
given case or not, will always be an embarrassing one for the practitioner 
to decide. I know of no better rule than to try diligently all the 
measures of treatment affording any prospect of relief until it becomes 
apparent that there is very little chance left for success, yet not carry the 
delay to the extreme of c\ anoses or the commencement of a death struggle, 
but with everything in readiness beforehand, let the operation be resorted 
to, just as thesis extreme conditions are approaching, instead of waiting for 
their full development. 

In such cases as I have described under the head of cedematous laryn- 
gitis, consisting of a rapid infiltration of serum into the areolar or con- 

* See Transactions of the Illinois State Medical Society for 1879 and 1880. 



392 LARYNGO-TRACHEITIS. 

nective tissue at the base of the epiglottis and between it and the vocal 
cords, in patients previously debilitated or anaemic, the danger of com- 
pletely shutting out the entrance of air at almost any inspiration usually 
makes the delay necessary for obtaining the effects of medical treatment 
extremely dangerous to the patient, and justifies an almost immediate re- 
sort to surgical interference. This interference may be by direct scarifica- 
tion of the cedematous part, as recommended and practiced by Dr. Gurdon 
Buck of New York, in 1847,* and by M. Lisfranc, at a much earlier 
period; or by opening of the larynx or trachea, as in the ordinary opera- 
tions for laryngotomy and tracheotomy. By passing the index finger of 
the left hand back over the tongue to the base of the epiglottis, the cedem- 
atous parts maybe felt as rounded prominences, and maybe freely incised 
or scarified by passing a properly guarded bistoury along the finger to the 
proper place and making two or three incisions into the most prominent 
part of the swollen tissues. 

By the surgeon possessing the extraordinary skill and tact of the late 
Dr. Buck, such scarifications may be readily and safely made. But those 
of less experience will find the struggle of the patient for breath, so in- 
creased by the presence of the finger which is to guide the bistoury, that 
it becomes extremely difficult to execute the necessary incisions without 
danger of injury to other parts. Practically, therefore, it is better and 
more certain to give relief to the patient, if the larynx or trachea is opened 
at once by the ordinary method. If the immediate danger of suffocation 
is obviated by the operation, the subsequent treatment wili depend mostly 
on the nature of the patient's previous sickness and the causes that may 
have provoked the attack. 

The treatment of chronic laryngitis, which occurs mostly in adult life 
and largely in connection with tubercular phthisis or syphilis, must be 
guided in a great degree by the nature of the constitutional affections 
with which it may be associated. If it is associated with tuberculosis the 
patient will need the same conditions of climate, hygienic relations, and 
general remedies for correcting the defects in nutrition as in any other 
case of phthisis ; while if it has a syphilitic origin the use of mercurials 
and iodides with proper attention to diet and drinks must be your chief 
reliance. Non-specific catarrhal cases may be treated on the same princi- 
ples and with the same remedies as I recommended to you in the preceding 
lecture on corresponding grades of inflammation in the nasal passages and 
pharynx. So long as no ulceration exists the local treatment should con- 
sist of moderate external counter-irritation by stimulating liniments or 
croton oil; and within the larynx, inhalations of a soothing anodyne and 
antiseptic nature will produce the best results. The frequent attempts to 
apply strong astringent and cauterizing remedies by means of the probang 
or sponge in such cases, are productive of more harm than good. 

In cases presenting well marked ulcerations so located that with the use 
of the laryngoscope you can make an application of nitrate of silver, sul- 
phate of copper, or iodoform, directly to the ulcerated surface, it will in 
many cases afford much relief. If it does, the application may be repeated 
every second or third day. But if after two or three applications the re- 
sult is an increase rather than a diminution of the patient's suffering, they 
should be discontinued. 

In the tuberculous cases all treatment will prove only palliative, but in 
those of syphilitic origin, even when the ulcerations are extensive, proper 
constitutional treatment aided by the local applications to which I have 

*See Transactions of the American Medical Association Vol. 1, Page 135 



BRONCHITIS. 39 ) 

alluded, will result in recoveries. In some of these, however, the cicatrices 
in the larynx cause so much contraction as to permanently destroy the 
action ot the vocal cords, causing incurable aphonia, and in some a degree 
q£ dyspnoea. Cases have also occurred in which the epiglottis was so far 
destroyed by the ulceration as to leave the glottis imperfectly guarded 
from the entrance of food and drink during deglutition. 



LECTURE XLI. 



Bronchitis— Acute and Chronic : Catarrhal, Mechanical, Capillary. Rheumatic, and Pseudo-mem- 
branous— Their Etiology, Clinical History, Pathological Anatomy and Diagnosis. 

GENTLEMEN: By the term bronchitis, I mean inflammation of some 
part or all of the membrane lining the bronchial tubes, from the 
bifurcation of the trachea to the air-cells, or alveoli, of the lungs. When 
the inflammation is produced by atmospheric or climatic influences, it is 
generally called catarrhal; when from the contact of dust or any irritating 
particles in the air, it is called mechanical; when it is located mostly in 
the fibrous structures of the air-tubes, it is called rheumatic; if accompanied 
by plastic exudation, it is called pseudo-membranous; and when the in- 
flammation occupies principally the smaller bronchial tubes, it is called 
capillary bronchitis. You may meet with these several varieties of 
bronchitis in all grades of activity, from the most acute to the most 
chronic grade of inflammatory action. 

History. — Bronchitis has been prevalent, especially in cold and variable 
climates, from the earliest records of human history; though not differen- 
tiated from inflammations of the larynx and trachea on the one side, or 
from those of the lungs and pleura on the other, until after the commence- 
ment of the nineteenth century. Although pretty accurate descriptions 
of bronchitis as a separate disease were given at an earlier period by 
Drs. Badham, Frank and Broussais, yet full and accurate descriptions of 
the disease, differentiating it from inflammation of other parts of the 
respiratory organs were not given until the discovery of auscultation by 
Ltennec, and its practical application to the physical examination of the 
chest. This important addition to the previous means for studying the 
?xact location and extent of all diseases within the chest, and the largely 
.ncreased attention given, about the same time, to the study of morbid 
anatomy, soon led to as accurate an appreciation of the existence and ex- 
tent of disease in any part of the organs of respiration and circulation as 
n any of the structures of the human body. 

Etiology. — The causes of bronchitis, like those of all other acute 
diseases, may be divided into two classes, namely, predisposing and ex- 
citing. Among the most common predisposing causes may be mentioned 
ige, sex, occupation or modes of life, and climatic influences. As a gen- 
eral rule, the several grades of bronchitis are more prevalent during child- 
hood and old age than during the active period of adult life. The British 
R"gistrar-General's report for 1868 contained 33,258 deaths attributed to 
bronchitis, being 1,344 for every million of inhabitants. Of the whole 



394 BRONCHITIS. 

number 10,5 50 died during the first three years of life, and 18,485 ovei 
forty-live years of age, leaving only 4,223 to occur between the ages of 
three and forty-five years. This, however, is very far from indicating cor- 
rectly the relative prevalence of the disease at the different periods of 
life, for the reason that the disease is far more fatal both in early child- 
hood and in old age than in the early and middle periods of adult life. 4 

During the months of February, March and April, 1882, in San Fran- 
cisco there were 65 deaths reported from bronchitis, of which 37 were ol 
children under five years of age, 25 of adults over forty years, and only 3 
of persons between five and forty years. During the same months there 
were reported 154 deaths from bronchitis in the city of Chicago, with 
about the same ratio in regard to age. In the city of Philadelphia during 
the seven years from 1862 to 1869, the deaths from bronchitis at all periods 
of life aggregated 969, of which 495 were of children under five years of 
age; 14 over five and under fifteen years, and 460 of persons over fifteen 
years of age.f 

These and similar mortuary statistics have led to the very general 
adoption of the opinion that early childhood and old age are pre-eminently 
susceptible to attacks of bronchitis. Yet my own clinical observations 
and records relating to the time and number of acute and subacute cases 
of bronchitis coming under my own care lead to a very different con- 
clusion. By reference to those records I find a larger number of cases 
occurring between the ages of ten and thirty years than at any other 
period of life. Thus, during the first six months of the present year 
(1882) I recorded 59 cases of primary bronchitis, that is, cases not arising 
secondarily as complications of other diseases. Of this number only 5 
were children under ten years of age; 38 between ten and forty years, 
and 16 over forty. It is probable that similar results will be obtained by 
all who will take the trouble to record the whole number of cases, instead 
of simply the number of deaths. The statistics of mortality in relation 
to this disease are deceptive, not only in regard to relative susceptibility 
of the human system to attack at the different periods of life, but also in 
regard to the ratio of mortality of the disease itself. It is generally con- 
ceded that the chief mortality from this disease occurs during infancy or 
early childhood and in old age, cases rarely terminating fatally in youth or 
the more active period of adult life. Careful examination of cases will 
show that this fatality at the extremes of life is owing mainly to the 
greater tendency of the inflammation at those periods to extend directly 
from the bronchioles into the lobules of the lungs, thereby complicating 
the bronchitis with lobular pneumonia. And in more than half the cases 
reported under the head of bronchitis, the fatal result was caused by the 
pneumonia, instead of the bronchitis. 

Sex. — Neither recorded facts nor my own clinical observations show 
any decided difference in the susceptibility of the sexes to attacks of 
bronchial inflammation. 

The influence of occupations, personal habits, and climatic conditions, 
as predisposing and exciting causes of inflammation in any and all parts 
of the respiratory mucous membrane, I explained to you sufficiently in 
the thirty- ninth lecture of the present course. What I then stated in 
regard to the causes of inflammation in the respiratory passages generally, 
is especially : pplicable to the bronchial part of those passages, and con- 
sequently need not be repeated here. I will therefore ask your attention 

* See Reynolds' System of Medicine, Amer. Edi ion, Vol. II p. 318. 

fSee A Practical Treatise on the Diseases of Children, by J. F. Meigs, M. D., and William 
Pepper, M. D.; Fourth Edition, page 189. 



SYMPTOMS. 305 

chiefly to the clinical history of the different grades of bronchial in- 
flammation. 

Acute Bronchitis. — The most common form of acute bronchitis, by 
inanv writers styled catarrhal bronchitis, acute bronchial catarrh, etc., 
presents considerable variety of symptoms according to the extent of the 
membrane involved and the intensity of the inflammatory process. As a 
general rule the disease commences with slight chilliness or unusual 
sensitiveness to slight changes of temperature, accompanied by a sense 
of soreness and oppression behind the sternum and sometimes across the 
whole chest, with a frequent and rather dry, harsh cough. In many cases 
there is during the first day or two coincident congestion of the mem- 
brane lining the nostrils, fauces and larynx, causing sneezing, with some 
feeling of soreness in the throat and hoarseness; also a heavy dull pain in 
the head, much increased by coughing. By the second day a moderate 
general fever has supervened, characterized by dryness and moderate 
heat of the skin, flushed face, slight increased frequency and fullness of 
the pulse, more sense of oppression and soreness in the chest, with a con- 
tinuance of harsh dry cough, which often causes soreness in the epigas- 
trium radiating laterally in the direction of the attachments of the dia- 
phragm to the inner surface of the ribs. On the second or third day the 
inflamed membranes begin to be less dry, and the paroxysms of coughing 
bring up a scanty expectoration of a tenacious, somewhat frothy mucus, 
which gradually increases until about the fourth or fifth day, when it 
becomes more opaque, sometimes yellowish, and much more easily ex- 
pectorated. At the same time that the expectoration changes to a more 
opaque condition, the general febrile symptoms begin gradually to abate, 
and the cough is accompanied by less sore pain, both in the chest and head. 

In the milder class of cases the decline in all the general symptoms is 
so rapid that by the seventh or ninth day convalescence is established. 
But in the more severe cases the more important symptoms may continue 
through two weeks and convalescence not be complete until the end of 
the third week. And in some of these cases the inflammation does not dis- 
appear on the subsidence of the febrile symptoms, but degenerates into a 
chronic form, causing a continuance of cough, with some muco-purulent 
expectoration and slight soreness in the chest, through an indefinite period 
of time. The disease is most likely to take this course when it occurs in 
young persons having a scrofulous diathesis; or in connection with 
eruptive fevers or pertussis; or in the aged afflicted with rheumatism. 
During the active stage of ordinary cases of bronchitis the urinary secre- 
tion is diminished in quantity, redder than natural, and deficient in chloride 
of sodium; and the bowels inactive. 

But after the crisis of the disease is passed, as indicated by the character 
of the expectoration, the renal and intestinal discharges soon return to 
their natural condition. The results of auscultation and percussion in 
ordinary bronchitis, limited to the membrane lining the larger bronchial 
tubes, are mostly negative. In some instances during the first, or dry 
stage, the respiratory or vesicular murmur may be slightly harsher or more 
dry than natural; and after exudation or secretion of mucus, as indicated 
by expectoration, there may be some coarse moist rales, which are re- 
moved temporarily by couching, but return again in a little time. These 
rales are heard much more in cases occurring either in infancy or in old age, 
than in youth or the middle period of adult life. Percussion elicits only 
the natural degree of resonance throughout the whole course of the 
disease, except in those rare cases in which complete occlusion of a 
bronchial tube has taken place, causing exclusion of air from certain 



396 BRONCHITIS. 

lobules of the lungs, and consequently a shade of dullness on percussion 
over such lobules. 

Mechanical Bronchitis. — By mechanical bronchitis is meant those cases 
in wliich the inflammation is caused by the direct action of mechanically 
irritating substances floating in the inspired air, as fine particles of steel 
and other metals, particles of stone, charcoal, and various vegetable pow- 
ders and fungi. Such substances when inhaled are liable to impinge on 
the surface of the bronchial membrane and produce direct irritation and 
inflammation, both acute and chronic. Cases orio-inatincr from this class 
of causes differ from the ordinary acute bronchitis, chiefly jn the mode of 
beginning and in the greater tendency to continue in the chronic form. 
Instead of slight rigors, coryza, and early development of moderate gen- 
eral fever, the patient generally complains, first, and for several days, of 
a sense of tickling or fullness in the air tubes, with occasional paroxysms 
of violent coughing and little expectoration. Sometimes particles of the 
foreign substance that is producing the inflammation may be seen mixed 
with the mucus or matter expectorated. In many of these cases there.is 
much soreness in the chest and considerable dyspnoea, especially during 
the night, followed by severe coughing in the morning and a more free 
discharge of mucus, occasionally containing little streaks of blood, but 
which is never intimately intermixed with the sputa as in pneumonia. 
If the patient, by change of occupation or otherwise, ceases to be exposed 
to the further action of the exciting cause, the symptoms soon begin to 
abate and a complete recovery may take place in from two to four weeks. 
If exposure to the further action of the exciting cause is not avoided the 
disease will necessarily assume a chronic form, and in many cases produce 
such changes as to materially shorten the life of the patient. 

Capillary Bronchitis. — By this term is meant inflammation in the 
smaller bronchial tubes, but not necessarily involving the true bronchioles 
as they terminate in the air-cells. It may arise from all the causes that 
are capable of exciting inflammation in the larger and medium-sized 
tubes. It is met with at any period of life, but is most frequent in in- 
fancy and early childhood, and next in persons past the middle period 
of life. The chief differences in the clinical history of this and the ordi- 
nary acute bronchitis arise from the greater obstruction to the ingress 
and egress of air through the inflamed tubes. The same degree of tume- 
faction of the membrane lining the smaller bronchi that occasions but 
little obstruction in the larger tubes, is capable of completely obstruct- 
ing many of the smaller ones, and thereby causing much dyspnoea and 
sense of oppression, with frequency of respiration, accompanied, at first, 
by an abundance of dry rales in all parts of the chest, followed later by 
the complete intermixture of dry sounds and moist sub-mucous rales; 
the latter caused by more or less exudation or secretion of mucus from 
the inflamed mucous membrane. The addition of the tenacious mucous 
exudation to the previous tumefaction of the membrane often so far ob- 
structs the ingress of air to the air-cells of the lungs, that the respiration 
becomes short, very frequent and noisy, with blueness of the lips, cold- 
ness of the extremities, drowsiness and soon death from suffocation. This 
result, however, is seldom met with except in quite young children and 
in persons enfeebled by age or by previous disease. In cases which 
do not thus tend to an early fatal result from the direct obstruction of the 
bronchi, the respirations continue frequent, in young children sometimes 
numbering fifty or sixty respirations per minute, with much dyspnoea and 
restlessness. The pulse is also very frequent but not in proportion to the 
respirations; the expression of countenance is anxious and often slightly 



SYMPTOMS. 397 

bloated, with a leaden hue of the prolabia; the wings of the nose expand 
and the chest heaves with each inspiration, giving a great variety of dry 
Whistling sounds throughout the whole chest, which, after the first two or 
three days become mixed with sharply defined sub-mucous rales, and in 
the later stages gives place to the latter entirely. The cough is frequent 
and inefficient on account of the difficulty of getting sufficient air to make 
it satisfactory. The temperature varies from 38° to 39.5° C. (101° to 
103° F.), seldom rising above the latter figure unless complicated with 
lobular pneumonia. The urine is generally scanty and deficient in the 
chlorine salts, and the bowels inactive. The labored efforts of breathing 
in many cases make the upper and anterior part of the chest appear more 
prominent than natural, and even more resonant on percussion on account 
of temporary emphysema from over-distension of the air-cells in those 
parts, while in some parts of the lower and posterior portions there is less 
expansion and less resonance than natural from the occlusion of some of 
the bronchi and the partial obstruction of others, leading to those parts 
of the lungs. 

Between the third and fifth days, usually, the mucous exudation, 
which up to that time had been scanty and tenacious, becomes more 
abundant and more opaque, and in two or three days more, assumes a dis- 
tinct muco-purulent character, and is much more easily expectorated. As 
that which comes from the smaller bronchial tubes is less mixed with air 
and consequently less frothy than that which comes from the larger tubes, 
the two qualities of matter may often be recognized in the same mouthful 
of sputa; and if the whole be placed in water, that from the smaller 
tubes will drop lower in the water, or sink to the bottom if detached from 
the other, which floats freely upon the surface. In acute cases, at the 
same time that the expectoration becomes more opaque and more easily 
dislodged by coughing, all the more important symptoms begin slightly 
to improve, and by the end of the second week convalescence is fairly es- 
tablished. Many cases, however, are less acute, slower in progress, and 
do not reach convalescence in less than three or four weeks. And many 
of this class manifest a strong tendency to continue indefinitely in a 
chronic form, more especially in persons past the middle period of life. 
In some of the cases that do not continue in a chronic form, the bronchial 
membrane is left in a condition of such susceptibility that the attack is 
renewed on the slightest exposure to the exciting causes. 

Rheumatic Bronchitis. — Although many systematic writers on practical 
medicine make no mention of this form of bronchitis, except as a com- 
plication of general rheumatic fever, yet cases, both of acute and chronic 
inflammation of the bronchi, of unmistakable rheumatic character, have so 
often come under my observation, that I am constrained to recognize it as 
a distinct form of disease. In regard to the relative frequency of the 
occurrence of this class of cases, I find in a brief report covering nine 
hundred and sixty-five cases of chronic pulmonary disease, read in the 
Medical Section of the American Medical Association, by Dr. F. H. 
Davis, in 1877, the following classification of the cases: 

Chronic catarrhal bronchitis 403 

" rheumatic '* 283 

" bronchitis accompanied by gastric derangement and spas- 
modic dyspnoea 119 

Chronic bronchitis, modified by syphilitic disease 37 

Hereditary pulmonary tuberculosis 56 



398 BRONCHITIS. 

Inflammatory pulmonary phthisis G7 

Total 965* 

You thus see that of the 842 cases of chronic bronchitis included in the 
table, the writer classes 28o, or a trifle more than thirty-three per cent., 
as of rheumatic character. That the relative proportion of acute 
rheumatic cases is less than those of a chronic grade I have no doubt; 
and yet their number is not so small as to be insignificant or unworthy oi 
careful attention. They differ in clinical history from ordinary acute 
bronchitis, chiefly in the following particulars: Etiologi -ally, a large 
proportion of them were in persons of a rheumatic diathesis, either hered- 
itary or acquired, and at those seasons of the year characterized by a 
predominance of cold and damp air, with frequent changes of tempera- 
ture. Their clinical history is characterized from the beginning by more 
continuous dull pain in the chest, often extending to the attachments of 
the diaphragm, the shoulders, and dorsal portion of the spine; by more 
persistent, dry, harsh cough, often exhibiting a marked spasmodic char- 
acter and accompanied by a great aggravation of the pains in different 
parts of the chest; and when the smaller bronchi are involved, the stage 
of dry rales is much more protracted, the dyspnoea and suffocative 
paroxysms of coughing more uniformly aggravated at night, and when 
mucous exudation does take place it remains scanty and viscid, rarely 
presenting a distinct muco-purulent character. During the active stage 
the urine is less in quantity, and more decidedly acid in reaction than 
natural, and the bowels generally costive. When not interfered with by 
appropriate treatment, these cases run a much more protracted course, 
and more frequently degenerate into a chronic form than those of an 
ordinary catarrhal character. When they are thus allowed to run a pro- 
tracted course, or to continue in a chronic form, they manifest another 
tendency of great importance, namely, to have the disease extend, by con- 
tinuity, from the fibrous and muscular structures of the small bronchi into 
the connective tissue of the pulmonary lobules, inducing sclerosis of the 
latter tissue and consequent compression or obliteration of the alveoli, or 
air-cells, and permanent contraction of the chest. Much and careful 
clinical observation has satisfied me that many of the cases now classed by 
writers as fibrous and inflammatory phthisis, begin as simple acute or sub- 
acute bronchitis, which, being renewed at every return of the cold, damp 
and changeable part of the year, not only ultimately cause permanent 
thickening of the bronchial structures, but gradually invade portions of 
the connective tissue of the lungs, and induce similar pathological changes 
in it, thereby causing obliteration of the alveoli and more or less shrink- 
ing of the chest. 

Pseudo- Membranous Bronchitis. — This affection has been described 
by different writers under the additional names of plastic, croupous or 
croupal, and diphtheritic bronchitis. The extension of the inflammation 
and membranous exudation to the bronchial tubes in cases of diphtheritic, 
and pseudo-membranous tracheitis and laryngitis, or croup, is of frequent 
occurrence. But as a distinct disease, limited to the bronchial membrane, 
you will meet with it very rarely. In 1854, Dr. T. B. Peacock noticed in 
the Transactions of the London Pathological Society thirty-four cases 
collected from European sources. Biermer, in 1867, increased the num- 
ber to fifty-eight. Kretschy, in 1874, added ten, and Chenstok four more 

* See Transactions of American Medical Association, Vol. 28, p. 269, 1877. 



SYMPTOMS. 3913 

making in all seventy-two cases in Europe. In 18? 0, D-. W. C. 

Glasgow, of St. Louis, read to the Medical Section of the American Med- 
ical Association an interesting report on the subject of Plastic Bronchitis, 
in which he notices twenty-three cases which had occurred in this country, 
accounts of which were obtained from an extensive correspondence with 
leading physicians in all parts of the United States, as well as Iroin care- 
ful search through our periodical medical literature. 

These statistics are certainly sufficient to show that the disease is of 
rare occurrence, both in this country and Europe. The statistics thus far 
collected, show a much greater prevalence of the disease in males than in 
females; and that the larger number of cases occur between the ages of 
fifteen and fifty years, although one case is reported by Dr. T. G. Simons, 
of Charleston, S. C, as quoted by Dr. Glasgow, at four years of age; and 
Goumcens, one at seventy-two. In a large proportion of the c ises re- 
ported, the disease existed in a chronic form. When acute, and affecting 
a iaroe portion of the bronchial membrme, it is liable to lead to an early 
fatal termination, from obstruction to the ingress of air to the air-cells of 
the lunjjs. But in many cases the disease occupies only a limited num- 
ber of the bronchi, and recovery has generally taken place in from two to 
three weeks. The symptoms differ from those of ordinary bronchitis in 
only two important particulars, namely: the more violent and suffocative 
character of the cough, and the actual appearance of shreds, patches, or 
casts of pseudo-membrane in the matters ejected by coughing. The lat- 
ter is the only reliable diagnostic symptom by which it can be certainly 
differentiated from all other forms of bronchial inflammation. When the 
membranous exudation is discharged in shreds or small pieces, it may 
readily escape the attention of the physician; and even considerable casts 
when expectorated are, in some cases, so surrounded with mucus and col- 
lapsed into a slightly yellowish mass in the central part of the mouthful 
expectorated that they might be regarded as only a mere muco-purulent 
part of the mucous secretion. If you throw the whole into water, how- 
ever, and agitate it a little, the membranous patches and casts will be 
quickly unfolded in such a manner as to be easily recognized. It is dis- 
tinguished from mucus, by leaving it in a solution of acetic acid, which 
causes it to swell, while mucus contracts in a similar solution. It has the 
appearance of having been formed in concentric layers, and is sometimes 
cast off so complete as to present a continuous representation of one or both 
primary and several of the secondary bronchial tubes. Under the micro- 
scope it has the same fibrillated appearance as other pseudo-membranous 
formations. 

Chronic Bronchitis. — Cases of acute and subacute bronchitis, belong- 
ing to either of the five varieties just described, may be protracted until 
they assume a chronic form; and other cases of each variety are met with 
which have been chronic from the beginning. This form of the disease 
is met with in aged persons, more frequently than at an earlier period of 
life. In children, it sometimes follows as a sequel of measles and whoop- 
ing cough, and in adults is often associated with tuberculosis, emphv- 
sema, and cardiac diseases. 

Etiology. — Chronic bronchitis is capable of originating from any and 
all the causes that have been enumerated as capable of producing the 
more acute forms of the disease, and consequently prevails most under 
the same conditions of tocography, climate, and social relations. 

Symptoms. — The symptoms of ordinary chronic bronchitis, differ from 
those accompanying the acute form of the disease chiefly, in the absence 
of general fever, and the existence of much less pain or feeling of sore- 



400 BRONCHITIS. 

noss and oppression in the chest. The patient generally complains of a 
cough, usually more severe on first retiring to bed at night and on rising 
in the morning, but occurring at intervals through the day, and accom- 
panied by a mucous or muco-purulent expectoration, varying much in its 
amount and tenacit}-. In the great majority of cases occurring in youn^ 
persons and in the first half of adult life, the expectoration is simply a 
whitish or slightly opaque mucus, more or less frothy from the intermix- 
ture of minute bubbles of air, and easily dislodged, especially in the 
mornings. In old persons, and in cases which have continued a long 
time, the expectoration often becomes more copious and more decidedly 
purulent, with slight feverishness at night, and some loss of flesh. In all 
the cases, except those last mentioned, the general health of the patients 
is but little impaired, the appetite and secrerions usually remaining near- 
ly natural. Those pursuing indoor occupations, or are sedentary in their 
habits, will be prone to constipation and imperfect digestion, more, how- 
ever, from the circumstances just mentioned, than from the effects of the 
bronchial disease. All cases of chronic bronchitis are subject to tempo- 
rary aggravation, by exposure to a cold and damp atmosphere, whether 
indoors or out; and are also very susceptible to increase from the inhala- 
tion'of air, containing dust or floating particles of solid matter, or of irri- 
tating gases. Cases of ordinary chronic bronchitis, rarelv prove fatal 
without the intercurrence of some other disease, and yet there is no natu- 
ral limit to their duration. In many cases the symptoms almost disappear 
during the warm months of summer, but return with the first period of 
cold and wet weather of autumn. Such patients usually find permanent 
relief by changing their residence to a mild and dry climate. 

The symptoms of the rheumatic grade of chronic bronchitis differ from 
those just described, mostly in the more severe paroxysmal character of 
the cough, with either no expectoration or only a scanty quantity of a 
glairy, tenacious mucus; more soreness or dull pain in the intercostal 
muscles and attachments of the diaphragm; and in the more marked 
influence of sudden and severe meteorological changes. Perhaps the 
most marked and distressing cases of this variety of bronchitis are those 
we occasionally meet with in old persons, whose joints, especially those 
of the extremities, have long been stiffened and sometimes enlarged from 
chronic rheumatism, and who are harassed and worn from a harsh, 
suffocative cough, the worst paroxysms of which are always during the 
latter part of the night and the early morning, accompanied by the ex- 
pectoration of considerable quantities of a thick, viscid, and very tena- 
cious mucus, which is dislodged with so much difficulty that in the midst 
of the more violent paroxysms of coughing the action of the stomach is 
reversed and its contents ejected by vomiting. This is very liable to 
happen just after breakfast and occasions the loss of the morning meal. 
The condition of these patients is very generally ameliorated during the 
warm months of summer, but on the whole they emaciate and grow 
more helpless from year to year, until they die from either exhaustion or 
the supervention of pulmonary sclerosis (fibroid phthisis), endocarditis, 
or chronic diarrhoea. There is one grade of rheumatic irritation which is 
liable to attack the fibrous texture of the smaller bronchi, and to give rise 
to a very persistent form of asthma, which increases with every returning 
cold season of the year, but as asthma in all of its forms is treated in other 
parts of this work, I only allude to it in this connection. 

Pathology and Morbid Anatomy. — The special pathology of inflamma- 
tion involving the mucous membrane and other structures of the bronchi 
does not differ from that of similar grades of inflammation in any other 



ANATOMICAL CHANGES. 401 

structures of the body. In the early stage of acute bronchitis you will find 
more or less intense congestion of blood in the vessels, causing redness 
and tumefaction of the membrane, soon followed by an increased flow of 
mucus, with increase or proliferation of mucous corpuscles and epithelium 
cells. 

In pseudo-membranous or croupous variety of bronchitis, you will find 
the bronchial tubes lined, and in some cases, filled with a plastic exudation. 
Usually, only a limited number of the bronchi are affected. The tube 
casts that may be expelled are generally in the form of balls that may be 
unrolled, and which will then be found to be fragments of the pseudo- 
membrane, or complete cylindrical casts of the tubes. They are, when 
expelled, usually yellowish and often tinged with blood. When washed 
they are usually white. There are frequently points of enlargement along 
the casts, which are caused either by the presence of air-bubbles within 
them, or by a more rapid exudation from that point on the bronchus. The 
largest casts are usually solid and laminated in structure; the smaller 
ones more frequently are hollow, containing a greater or less number of 
air-bubbles; the smallest consist of a single solid thread. Under the 
microscope the casts seem to be composed of a structureless or fibrous 
substance, holding numerous mucous and pus cells, more or less numerous 
globules of fat, and occasional epithelial cells; seldom red blood corpuscles, 
although these may be numerous on the surface. 

The casts are usually moderately compact, firm and elastic. Toward 
the end of the disease, however, they may be less firm. In some cases 
toward the close of life epithelial cells are abundant in them, but in other 
cases on post mortem examination the epithelial lining of the bronchi is 
found nearly or quite entire. The mucous membrane may be much red- 
dened, or on the other hand, paler than normal. The sub-mucous tissues 
are also sometimes involved in the swelling, and occasionally infiltrated 
with serum, while leucocytes or white corpuscles are seen permeating the 
capillary walls and penetrating the sub-mucous tissue, or mingling with 
the increased epithelium upon the surface. The several inflammatory 
products are seen adhering to the surface of the inflamed membrane and 
in the smaller tubes, often so filling their caliber as to greatly interfere 
with the ingress and egress of air through them, and of course adding to 
the dyspnoea that characterizes the capillary form of bronchitis. During 
the later stages of the disease you will see pus corpuscles freely inter- 
mingled with the mucus, and owing to the exfoliation of much of the 
epithelium, the surface of the mucous membrane often appears irregular, 
abraded, or ulcerated. When the inflammation has been protracted into 
a chronic form, the vessels appear less congested, but the cell proliferations 
continue both in the mucous and sub-mucous structures, causing thickening 
and increased density, with a still more purulent quality of secretion. 
The bronchial glands are also sometimes seen enlarged, and either soft- 
ened, colored with pigment, or, more rarely, calcified. In addition to 
the foregoing changes, in many cases of the capillary form of bronchitis 
you may find some lobules of the lungs collapsed from the complete oc- 
clusion of the bronchi leading to them, by the accumulation of tenacious 
mucus with other inflammatory products. And in the same cases the air- 
cells in other parts of the lungs, more frequently the upper and anterior 
parts, are enlarged from over-distension constituting a degree of emphy- 
sema. In very chronic cases, especially of the rheumatic variety, you may 
find considerable hypertrophy of the connective tissue of the bronchi, and 
in other cases atrophy of the same tissue, the latter generally accompanied 
by more or less dilatation of the tubes. 

26 



402 BRONCHITIS. 

For a representation of one of the most complete specimens of pseudo- 
membranous casts from the bronchi, the reader is referred to the paper of 
Dr. Glasgow in the transactions of the American Medical Association, 
already referred to. 

Diagnosis. — The principal diseases from which acute inflammation of 
any part of the bronchial, mucous membrane needs to be differentiated, 
are pneumonia, pleurisy, laryngitis, tracheitis, and asthma, while it is still 
more important to keep a clear line of diagnosis between the chronic 
grades of bronchial inflammation and the earlier stages of pulmonary 
phthisis and of emphysema. From nearly all the diseases named it is 
separated by negative evidence or the absence of symptoms and physical 
signs which necessarily exist in those affections. You find in bronchitis 
neither the rusty expectoration, nor high temperature, nor fine crepitant 
rales of pneumonia; nor the acute pains or short, stifled cough or friction 
sounds of pleurisy in the early stage; and still less will you find in the 
middle and later stages, any of the dullness on percussion that character- 
izes the corresponding stages of the other two diseases. In true asthma 
the active symptoms are distinctly paroxysmal, without fever or increase 
of temperature, and the respirations during the paroxysms are slow, with 
marked prolongation of the expiratory act; while in bronchitis, both in 
the larger and smaller tubes, the symptoms are continuous, the tempera- 
ture increased, and the respirations more frequent than natural. All 
grades of bronchitis are easily distinguished from laryngitis and tracheitis 
by auscultation, which will enable you to trace all the morbid sounds to 
the chest in the former, and to the front part of the neck in the two 'atter. 
The great advantage to the patient of having pulmonary tuberculosis, and 
other forms of phthisis, recognized in the early stage of the disease, makes 
the diagnosis between it and chronic bronchitis a matter of primary im- 
portance. This you can readily do if you take the trouble to acquire a 
reasonable degree of skill in the practice of auscultation and percussion. 
In all forms and stages of pulmonary phthisis, whether from primary tu- 
bercular deposits, pneumonic exudation followed by caseous degeneration, 
or from interstitial fibroid sclerosis, you will find increased vocal fremitus 
and diminished resonance on percussion; neither of which are present in 
any grade of uncomplicated bronchitis. 

It is true that in the advaticed stage of some very severe cases of capil- 
lary bronchitis there occurs sufficient oedema to increase the vocal fremitus 
and diminish the resonance over some parts of the chest. But the ac- 
companying symptoms and immediately preceding history of such cases 
;is sufficient to separate them from any stage of phthisis. 

The same remark is applicable to those rare cases in which an attack of 
pseudo-membranous bronchitis results in the complete occlusion of one or ] 
more of the bronchi and the permanent collapse of the pulmonary lobules 
to which the occluded tubes lead. If in addition to the plain difference 
in the physical signs already mentioned, you remember that in all the 
iforms of phthisis there is progressive loss of flesh, some increase of tem- 
perature, and acceleration of pulse, with a contraction of the anteropos- 
terior diameter of the upper part of the chest, while none of these changes 
.usually result from bronchitis alone, you will find no difficulty in keeping 
the line of diagnosis clear between these two diseases. And yet there is 
probably no more frequent or important error committed in diagnosis than 
that of mistaking the early stage of pulmonary phthisis for bronchitis. 
This may arise in part from the fact that bronchitis often supervenes and 
continues coincidently with phthisis. But you must remember that 
whenever there is increased vocal fremitus and diminished resonance in 



DIAGNOSIS. 403 

anv given case, there is some altered condition of the lung structure, and 
consequently some form of disease besides bronchitis, however plain the 
ordinary symptoms of the latter may be at the same time. You can dis- 
tinguish pulmonary emphysema from chronic bronchitis by the abnormally 
increased resonance from percussion in the former, especially over the 
upper and anterior parts of the chest, and in the peculiar depression of 
the spaces above the clavicles and between the ribs at the beginning of 
the inspiratory act, and their return to over fullness near its close, while 
none of these changes accompany any grade of simple bronchial inflam- 
mation. 



LECTURE XLII 



Bronchitis— Its Varieties continued ; Their Prognosis and Treatment. Asthmatic Bronchitis— 
Catarrhal Asthma— Hay-Fever ; Their Clinical History and Treatment. 

GENTLEMEN: In the preceding lecture I directed your attention 
chiefly to the clinical history of the different varieties and grades of 
bronchitis, the pathological changes which take place in the inflamed 
structures during their progress, and their diagnosis or differentiation from 
other affections of the respiratory organs. I now direct your attention to 
their prognosis and treatment. 

Prognosis. — The prognosis in bronchitis depends much upon the 
particular part of the membrane affected, the grade of the inflammatory 
process, the age, and the previous condition of the patient. When the 
inflammation is limited to the lining of the larger and medium sized air 
tubes, and is not of the plastic or pseudo-membranous variety, there is 
but little tendency to produce fatal results at any period of life, especially 
if the patients have not been debilitated by previous disease or affected by 
some constitutional predisposition. When the membrane lining the smaller 
tubes is the seat of disease, constituting capillary bronchitis, there is more 
danger to life, especially in young children and in old persons. In the 
more severe attacks involving both sides of the chest, the obstruction to 
the passage of air through the smaller bronchi, caused by the congestion and 
rapid accumulation of inflammatory products occurring in infancy or in 
those much enfeebled by age, death from apncea or insufficient supply of 
air to sustain the function of respiration, is liable to occur in from three 
to seven days. Another source of great danger in this class of cases is 
from the supervention of lobular pneumonia. For these reasons the 
capillary form of acute bronchitis has resulted in a moderately high ratio 
of mortality. 

The pseudo-membranous variety of the disease is still more dangerous, 
especially when the inflammation invades a large number of the bronchi; 
and for the obvious reason that the adhering plastic material constituting 
the false membrane, being difficult to dislodge, is much more liable to 
accumulate until it present-; a fatal obstruction to the ingress of air. 
When the disease is limited in its extent or is of a chronic grade of 
activity there is a good prospect of recovery. The duration of acute 



404 BRONCHITIS. 

bronchitis of all varieties, when it ends in the recovery of the patient, is 
from one to three weeks. The chronic forms of bronchitis, when uncom- 
plicated by other diseases or constitutional cachexias, seldom terminate 
fatally; and yet they manifest no tendency to a self-limited duration. 
Many of this class of cases improve much during the warmest months of 
summer, and are regularly aggravated by the return of cold and wet changes 
in the autumn. In other cases you will find the changes of the seasons 
to produce but little effect on the symptoms or progress of the disease, 
and yet the patients live out their three score and ten years. 

Treatment. — The indications to be fulfilled or objects to be accom- 
plished in the treatment of the different grades of bronchitis, are the same 
as I have stated to you in speaking of the treatment of inflammation in 
other parts of the respiratory mucous membrane, namely: to diminish 
the morbid excitability of the inflamed structure; to lessen the local 
hyperasmia and thereby limit the amount of exudation and accumulation 
of inflammatory products; to counteract secondary functional disturbances 
by lessening febrile heat and promoting the eliminations from the skin and 
kidneys, and to hasten the disintegration and removal of such plastic 
exudations as may have taken place either upon the surface or into the 
texture of the inflamed membrane. Of course, you must at all times give 
due attention also to the regulation of the diet, drinks, exercise, clothing, 
temperature and all other hygienic matters influencing your patients. 

The three first objects I have named as desirable to accomplish belong 
more particularly to the early stage of acute and subacute attacks, but 
are present in some degree throughout the whole course of the disease; 
while the last belongs to the later stages of the acute, and to all stages 
of the chronic grades of the inflammation. While the foregoing indica- 
tions to be fulfilled or objects to be accomplished, are present in all the 
various grades and stages of inflammation of the bronchi, the particular 
means for accomplishing them will be modified by the age and previous 
physical condition of the patient; the nature of the predisposing and ex- 
citing causes; the extent of the disease, and the stage of its advancement; 
or, in other words, the nature and extent of the pathological changes al- 
ready accomplished. For instance, the same remedial agents that would 
be most efficient in relieving the morbid excitability and the vascular full- 
ness of the first stage of acute inflammation in a young or middle-aged, 
and previously healthy, vigorous subject, mi^ht be positively injurious or 
even fatal if used in the same stage of inflammation in a subject pre- 
viously anemic and feeble, or debilitated from age, or from causes ca- 
pable of impairing the quality of the blood and favoring a typhoid condi- 
tion of the system. Consequently the practitioner, who not only sees 
clearly the objects most desirable to accomplish, but who most judiciously 
selects and adjusts the means or agents he uses to the special conditions 
of each patient, will meet with the highest degree of clinical success. 
In the first stage of acute attacks, involving the bronchi of both lungs, in 
vigorous adult persons, and especially if the inflammation extends into 
the smaller tubes causing much dyspnoea and dry rales, there is no single 
remedy that will so certainly and speedily check the intense engorgement 
of vessels in the bronchial membrane, and thereby gain time for the ac- 
tion of other remedies, as one prompt and liberal abstraction of blood by 
venesection. In cases of a little less severity, and in children, the appli- 
cation of from two to twelve leeches to the upper and anterior part of the 
chest, the number being regulated by the age of the patient, will be a 
good substitute for the venesection. And in case leeches are not at hand, 
extensive dry cupping over both the anterior and posterior parts of the 



60.0 


c. c. 


|ii 


75.0 


u 


riiss 


15.G 


u 


rSS 


6.0 


u 


3"ss 



TREATMENT. 405 

chest, may be applied with much benefit. Immediately after the venesec- 
tion, leeching, or cupping, and without these, in cases of only ordinary 
severity, the whole chest may be enveloped in an emollient poultice 
or in folded napkins, wet in warm water and covered with oiled silk; 

and at the same time the following combination may be given inter 
nally: 

i£ Liquor Ammonii Acetatis, 
Tincturse Opii Camphoratae. 

Vini Antimonii, 
Tincturse Yeratri Viridis, 

Mix. Give to an adult four cubic centimeters, or one teaspoonful, in a 
tablespoonful of water, every two, three, or four hours according to the 
severity of the case. The same may be given to children, the dose being 
properly adjusted to the age of the child. If you find the tongue coated, 
the bowels inactive, and urine high colored, from six to thirty centigrams 
(gr. i to v) of calomel, according to the age of the patient, may be given 
and followed in four or five hours by a saline laxative sufficient to procure 
two or three evacuations from the bowels. Under the influence of these 
remedies, the high fever and great sense of soreness and oppression in the 
chest, which exist in the first stage of the more acute cases, in previously 
healthy subjects, rapidly diminish, giving place to more moist rales, 
easier breathing, and some expectoration. As soon as such amelioration 
of symptoms has been obtained, you may discontinue the mixture con- 
taining veratrum viride, and substitute the following formula, in its place: 

j}, Syrupus Scillae Compositi, 45.0 c. c. ^iss 

Tincturse Sanguinariae, 15.0 " 3SS 

Tinctune Opii Camphoratae, 60.0 " §ii 

Mix. Give to an adult four cubic centimeters, (fl. 3i) in a little 
additional water, every three or four hours. If the patient suffers much 
from severe, sore pain in the head, aggravated by coughing, or from nerv- 
ous restlessness, you may add of bromide of potassium sixteen grams 
("iv) to the aboye formula, which will render it more efficient in relieving 
those symptoms and in promoting rest. Under such quieting and ex- 
pectorant influence, aided by a mild laxative when needed, the cough, sore- 
ness and oppression in the chest, and all other active symptoms, usually 
diminish from day to day, and convalescence ensues in from seven to nine 
days. If, after the first three or four days, you find the temperature to 
rise in the evening and the couo-h to become more troublesome, interfer- 
ing with rest during the first part of the night, followed by some sweat- 
ing in the early morning, a single dose composed of sulphate of quinia 
from three to six decigrams (gr. y to x) pulverized sanguinaria root three 
centigrams (gr. +), and codeine sixteen milligrams (gr. ^), given between 
six and eight o'clock each evening, for three or four evenings, will often 
contribute much to the rest of the patient and hasten the establishment of 
convalescence. You will sometimes meet with cases, especially in pa- 
tients debilitated by previous ill-health or aj;e, in which the fever subsides 
after the first three or four days, leaving the patient with a feeling of un- 
usual weakness, a deep, harassing cough and copious muco-purulent ex- 
pectoration, and little or no appetite. In such cases tonics and the more 
stimulating class of expectorants are indicated. You can give a mixture of 
equal parts of the syrup of primus virginiana, syrup of senega, and cam- 
phorated tincture of opium, in doses ol four cubic centimeters or one tea- 



406 BRONCHITIS. 



spoonful every four or six hours, and thirteen centigrams (gr. ii) of qui- 
nine three times a day, and it will generally produce a rapid improvement 
in all the symptoms. In some of the cases last decsribed there is added 
to the other symptoms a troublesome nausea and disposition to vomit with 
the paroxysm's of coughing, in which I have found the following formula 
a good substitute for the mixture containing the prunus virginiana and 
senega: 

fy Acidi Carbolic!, 0/0 grams gr. viii 

Glycerinae, 30.0.0 c c. "i 

Tincturse Opii Camphnratae, 00.00 " 311 



Aquae, 60.00 



3 11 



12.00 grams 
0.13 " 
0.20 " 

30.00 c. c. 


3iii 
gr. ii 
gr. iii 
|i 


90.00 " 


gitt 



Mix. Give four cubic centimeters (fl. 3i), or one teaspoonful before 
each meal time and at bed time, giving the quinine a little after the 
meals. If more anodyne influence is required to procure rest at night, 
you can add sixteen milligrams (gr. ^), of codeine to the teaspoonful oi 
carbolic acid mixture, given at bed time. 

If, as sometimes happens in cases of acute bronchitis, both of the 
catarrhal and capillary varieties, the inflammation invades some of the 
lobules of the lungs, as indicated by undue rise of temperature, greater 
expansion of the wing of the nose during inspiration, with short expira- 
tion, and diminished resonance with fine crepitation over limited portions 
of the chest, you will find the most certain and speed}' relief to follow 
the application of a blister over the seat of the pneumonia and the in- 
ternal use of the following formula: 

Tp Ammonii Muriatis 

Antimonii et Potassii Tartratis 
Morphiae Sulphatis 
Extracti Glycyrrhizae Fluidi 
Syrupus Simplicis 

Mix. Give to adults four cubic centimeters (fl. 3i), mixed with a table- 
spoonful of water every three or four hours, until some relief is obtained, 
and then at longer intervals. For children you should diminish the 
doses in proportion to the diminution of age. Quinine and laxatives may 
be used in these cases, under the same indications as in uncomplicated 
bronchitis. In the severe attacks of capillary bronchitis in young 
children many writers recommend emetics and subsequently nauseating 
doses of antimony or ipecacuanha. But I have not seen sufficient benefit 
to result from emetic doses of these agents to compensate for the early 
prostration, and sometimes continued gastric irritability, which they are 
liable to induce. I prefer the proper application of leeches at the very 
beginning, followed by emollient applications to the chest, and the same 
remedies internally as already mentioned, aided, perhaps, by an earlier 
use of quinine and digitalis, if the cardiac action becomes weak and 
frequent. In all this class of cases, however, much caution should be 
exercised in regard to the use of opiates, either alone or in combination 
with other remedial agents, lest their narcotizing influence should diminish 
the force and frequency of the respiratory movements too much, and en- 
courage the accumulation of the inflammatory products in the smaller 
bronchi to such a degree as to produce apncea or death from the exclusion 
of air from the alveoli, or air-cells of the lungs. And yet, just enough of 



TREATMENT. 407 

these quieting agents to diminish excitability and allay excessive restless- 
ness is as desirable in children as in adults. In. the plastic, or pseudo- 
membranous form of bronchitis it is an object of much importance, in the 
tii^t stage, to limit the amount of plastic exudation, and later, to hasten 
the loosening and disintegration, or discharge of such layers of false 
membrane as may have formed on the bronchial mucous surface. For 
these purposes you may give alterative doses of calomel alternately with 
the doses of the formula containing the liquor ammonii acetatis already 
given, during the first twenty-four hours; and subsequently, pretty full 
doses of the iodides of sodium or potassium, or of the bi-carbonates. In 
acute cases in children, when the symptoms indicate that the false mem- 
brane is loosening and the dyspnoea is great, an emetic that will induce 
prompt and free vomiting may hasten its expulsion and afford much relief. 
In the cases which I have described as rheumatic bronchitis of the more 
acute or active grade, the most prompt and satisfactory degree of relief 
has been obtained by the administration of the following combination of 
remedies in the early stage: 



Sodii Salicylatis 

Glycerinae 

Vini Colchici Radicis 


25.00 grams 3^i 
15.00 c. c. 3iv 
25.00 " 3vi 


Syrupus Scillae Compositi 
Tincturae Opii Camphoratee 


45.00 " 3jss 
60.00 « ?jj 



Mix. Give four cubic centimeters (fl 3i) every three or four hours, in a 
little additional water. In several cases in which this grade of inflamma- 
tion was located chiefly in the smaller bronchi, causing very distressing 
and persistent dyspnoea, I have given an equal mixture of the wine of 
colchicum root and the acetated tincture of opium, in doses of twenty- 
five to thirty minims every three hours at first, with more benefit than any 
other remedies I had used- And after some degree of relief had been 
obtained by lengthening the interval between the doses to four or six 
hours, and continuing it a few days, all the symptoms were removed. 

When the disease occurs in old persons, accompanied by severe 
paroxysms of coughing, and only a scanty and very viscid mucous expec- 
toration, much benefit may sometimes be derived from the use of the car- 
bonated alkalies, such as the carbonate of ammonium, or bi-carbonate of 
sodium, dissolved in an equal mixture of the fluid extract of the phytolacca 
decandria, liquor ammonii acetatis, and camphorated tincture of opium, 
in such proportion that the patient will get three decigrams (gr. v), of 
carbonate of ammonium in each dose of the mixture. It is proper to re- 
mind you, however, that there are many mild attacks of bronchitis, caused 
by exposure to sudden and severe meteorological changes, which, if seen 
during the first twenty- four hours, can be speedily arrested by a hot or 
stimulating foot bath and a full dose of the compound powder of opium 
and ipecacuanha (pulv. Doveri), taken in the evening, and followed the 
next morning by a saline laxative, and two or three moderate doses of 
quinine during the day. Similar results can also be obtained, in some 
cases, by the use of any agents that will allay irritability and at the same 
time produce a free or copious elimination from the skin and kidneys. An 
efficient diaphoretic dose of pilocarpin, or a full warm bath, followed by 
two or three moderate doses of quinine will succeed well if employed in 
the initial stage of the disease. Unfortunately, but few patients will apply 
to you for aid until after this stage has passed. 

Treatment of Chroni>: Bronchitis. — Most of the cases of chronic bron- 



408 BRONCHITIS. 

chitis are treated satisfactorily by a more moderate use of the same 
remedial agents that have been recommended in the acute and subacute 
grades of the disease; aided by a judicious regulation of diet, dress and 
exercise. In a great majority of the cases of ordinary chronic bronchitis 
the formula already given, containing the muriate of ammonium, or the one 
containing the compound syrup of squills, if given to adults in doses of 
four cubic centimeters (fl 3i) before each meal and at bed-time, mixed 
with a table-spoonful of water, will afford the necessary relief without 
confining the patients to the house. If the bowels become constipated 
while using either of these prescriptions, the evil may be obviated by 
taking one of the following pills every evening: 

fy Extracti Hyoscyami 2.00 grams gr. xxx 

Ferri Sulphatis, 2.00 " " xxx 

Pulveris Aloes, 2.00 " " xxx 

Pilulae Hydrargyri, 2.00 u " xxx 

M. ft. pillulas, xxx — If one pill taken every evening does not prove 
sufficient to prompt one natural intestinal evacuation each morning, you 
can order another to be taken after breakfast. The patients should 
adhere to a plain, nutritious and easily digestible diet, avoiding the use of 
all varieties of alcoholic drinks; wear good flannel underclothes all the time; 
and take moderate daily out-door exercise, so long as their strength will 
permit. In addition to the several remedies that have been mentioned as 
applicable to the treatment of the different varieties of acute and subacuce 
bronchitis, there are many others which I have found more or less 
beneficial in the treatment of chronic cases. Among the more important 
of these are the iodides of potassium and sodium, the grindelia robusta, 
eucalyptus globulus, Oenothera biennis, cimicifuga racemosa, asclepias 
tuberosa, balsams copaiba and tolu,gum benzoin, turpentine, cod-liver oil, 
and the hypophosphites of soda, lime and iron. Others have used a still 
larger number of remedies by inhalation. As a general rule, where you 
find the cough harsh and the expectoration scanty, with the predominance 
of dry rales, you will obtain the best results from the use of such remedies 
as the muriate and iodide of ammonium and the iodides of potassium and 
sodium, given in conjunction with small doses of antimony and some mild 
anodyne. On the other hand, if you find the expectoration abundant and 
of a muco-purulent character, the balsamic and terebinthinate remedies 
given in connection with such tonics as the lacto-phosphate of calcium, 
phosphate of iron, sulphates of quinine and strychnine, with codia, 
nyoscyamin, or lupulin at night, to procure rest, will afford the greatest 
relief. In some of these cases I have obtained very good effects from a 
combination of two parts of the syrup of iodide of calcium with one of the 
fluid extract of hops, given in doses of four cubic centimeters (fl 3') 
each morning, noon, tea-time, and bed-time. When chronic bronchitis is 
complicated with pharvngitis and laryngo-tracheitis much palliative 
influence may be obtained by judiciously directed inhalations, either in 
the form of vapor or atomization. But when the disease is limited to the 
bronchi alone, inhalations produce much less influence over its progress, 
or in relieving the more distressing symptoms. And unless the nature of 
the material used is judiciously selected with reference to the particular 
stage and grade of the disease, the inhalations will be more likely to do 
harm than good. There are two conditions of the bronchi met with in 
different cases of chronic bronchial inflammation, to which local appli- 
cations can be made in the form of vapor, by inhalation, with much benefit. 



TREATMENT. 409 

The first is indicated by an abundant purulent or mueo-purulent ex- 
pectoration, sometimes fetid and at other times not. For such the full 
deep inhalations of aqueous vapor impregnated with some antiseptic and 
anodyne, will be of great service. One of the best combinations that can 
be used lor this purpose is that of carbolic acid with camphorated tincture 
of opium in the proportion of two grams of the fo. mer (gr. xxx) to ninety 
cubic centimeters (^iii) of the latter. 

Four cubic centimeters (fl. 5i), of this mixture may be put into 250 
cubic centimeters (fl. 3 viii), of hot water in an inhaling bottle, and the 
vapor inhaled freely five minutes at a time two or three times each day. 
The second condition alluded to is characterized by a persistent, harsh, 
irritative cough, with little or no expectoration, indicating a sensitive and 
congested condition of the mucous membrane, with no natural secretory 
action. Such cases may generally be much relieved by adding to the 
antiseptic and anodyne mixture just given, some one of the oleo-resin or 
balsamic preparations, of which, perhaps, none are more efficient than that 
which is known in the shops as oil of Scotch pine. Four cubic centi- 
meters (ji), of this may be added directly to the quantity of the other in- 
gredients already given, and then used in the same manner. The com- 
bination thus used appears to allay the morbid sensitiveness and speedily 
establish a better secretory action. There is another important class of 
cases, met with most frequently in persons of both sexes between twelve 
and twenty years of age. They present a narrow, imperfectly developed 
chest, with so sensitive a condition of the bronchial membrane that every 
trifling exposure to cold and damp air renews the vascular hyperemia and 
cough until both become permanent, and the morbid process extends into 
the connective tissue of the pulmonary lobules, establishing what some 
call interstitial pneumonia, and others, fibroid phthisis. In the earlier stage 
of all of this class of cases the systematic daily practice of full, deep inhala- 
tions of pure atmospheric air, coupled with a judicious exercise of the 
muscles of the chest and arms will do more to remove all symptoms of 
bronchial disease and preserve the general health of the patient, than all 
the medicines that have been hitherto devised. There is much evidence 
in favor of u^ing compressed air for inhalation in these and some other 
cases of chronic bronchial inflammation. The late Dr. F. H. Davis, of 
this city, who, during his brief professional career, gave much attention 
to the treatment of diseases of the respiratory organs, and who had good 
opportunities for clinical observation, says, when speaking of the same 
class of young subjects, that, " The inhalation of compressed air for from 
live to ten minutes once or twice a day produced marked and rapid im- 
provement in all the cases. The s'ze of the chest, on full inspiration, 
was increased from one-half inch to one inch in the first month, and a habit 
of fuller, deeper breathing and a more erect carriage was established."* 

But he adds, with proper emphasis, that the inhalations to be perma- 
nently curative must be continued faithfully for many months, and be 
accompanied by a judicious regulation of all the habits of life. Every 
physician of much practical experience knows, however, that in defiance of 
ali the remedies and methods of treatmen: hitherto devised, there are many 
cases of chronic bronchial inflammation which will continue and be aggra- 
vated at every returning cold season of the year so long as the patient lives 
in a climate characterized by a predominance of cold and damp air, with fre- 
quent and extreme thermometric changes. And yet a large proportion 
of these, by changing their residence to a mild and comparatively dry 

* fee paper read be r ore the Chicago Society of Physicians and surgeons, April, 1877, on the Ee.- 
piratiun of Compressed and Rarilied Air in Pulmonary diseases. 



410 ASTHMATIC BRONCHITIS. 

climate, either greatly improve or entirely recover. Consequently, in all 
the more severe and persistent cases such a change is of paramount im- 
portance, and should be made whenever the pecuniary circumstances of 
the patient will permit. Probably the best districts in our own country 
to which the class of patients under consideration can resort are the 
southern half of California, the more moderately elevated places in New 
Mexico and the western part of Texas, Mobile in Alabama, Aiken in 
South Carolina, and most of the interior parts of Georgia and Florida. 
My own observations lead me to the conclusion that the unfortunate 
invalid suffering from any grade of bronchial inflammation can find in 
some one of the regions I have named, all the relief that he could gain 
in the most celebrated health resorts on the other side of the Atlantic. 

In cases accompanied by known scrofulous or other cachectic conditions 
involving general impairment of nutrition in which sea air, in connection 
with mildness of climate would be desirable, the Bermuda Islands may 
be resorted to with a prospect of much benefit. In selecting places of re- 
sort for the classes of invalids under consideration, care should be exer- 
cised to prevent their choosing a residence on a wet soil on the one hand, 
or in a region subject to much dust, sand, or other particles of matter 
floating in the air, on the other. The latter constitutes a serious objec- 
tion to many parts of the elevated plains lying on either side of the great 
mountain chain running parallel with our Pacific coast You should also 
remind all these patients that faithful adherence to strictly temperate and 
judicious habits of life, with regular daily outdoor exercise, is essential to 
their welfare in whatever climate they may choose to live. 

Asthmatic Bronchitis — Catarrhal Asthma — Hay Fever. — Perhaps 
there will be no better time during the college term than the present, 
to call your attention to a brief consideration of certain morbid conditions 
of the bronchi, which involve both an undue sensitiveness and congestion 
of the lining membrane to such a degree as to approximate closely a true 
inflammatory condition. The cases which will come to you under the 
popular name of asthma, may be divided into two classes. The cases be- 
longing to one class, are characterized by paroxysms of dyspnoea of tempo- 
rary duration, with intervals of entire absence of all respiratory symptoms or 
febrile phenomena. These are dependent on some form of nervous derange- 
ment, either direct or reflex, and consequently will receive due attention 
in the third division of local diseases. Those belonging to the other class 
are characterized by some degree of persistent morbid sensitiveness of 
the mucous membrane, both of the nasal and bronchial passages, with more 
or less frequent attacks of dj'spncea, generally aggravated during the 
night, partially subsiding during the day, and lasting from three or 
four days to as many months. This class of cases are divisible clinically 
into three groups. The first group embraces such cases as are associated 
with a chronic, rheumatic or gouty diathesis or are symptomatic of renal 
or cardiac diseases. In such, the paroxysms of bronchial constriction 
or asthma occur at entirely irregular intervals, or whenever accidental 
causes supervene, without regard to special periodicity or season of the 
year. The second group embraces such cases as recur at the commence- 
ment of every cold season and continue with varying degrees of severity 
until the commencement of the following summer. The third group em- 
braces those peculiar cases which are strictly periodical, recurring at a 
given time during the warm season of each year, . ome commencing in 
June, some in July, and a much larger number in August, and conse- 
quently are popularly called hay asthma, or hay fever. In the first group 
of cases the symptoms during the intervals between the paroxysms belong 



SYMPTOMS. 411 

rather to the associated constitution il or local affections, than to the 
bronchial trouble; yet in nearly all of them there is slight habitual cough 
and shortness of breath with some wheezing whenever attempting very 
active exercise. Ill most instances the active paroxysms commence in 
the night, without any premonitory nasal or catarrhal symptoms, and are 
characterized by great sense of tightness or constriction in the chest, ex- 
treme dyspnoea, the act of inspiration and expiration being both difficult 
and prolonged as if the air was forced through very narrow tubes and ac- 
companied both in the ingress and egress by all grades of dry sounds, 
from the rough and sonorous to the finest, sibilant and piping. The pa- 
tient is obliged to sit upright, and presents a rather full and anxious ex- 
pression of countenance; slight elevation of temperature; moderate accel- 
eration of the pulse; coo! and congested appearance of the surface of the 
extremities; suspended digestion ; inactive state of the bowels,, and the 
urine sometimes copious and limpid as water, at others scanty and high 
colored. 

As the morning approaches the dry rales become mixed with sharply 
denned sub-mucous rales and more frequent attempts to cough, with a 
scanty amount of white, frothy expectoration. The patient complains of 
great weariness and desire to sleep, without the ability to do so. In most 
cases by daylight, the dyspnoea has so far abated that the patient can re- 
cline at an angle of forty-five degrees, and sleep from ten to fifteen min- 
utes at a time, from which he rises suddenly to the upright position and 
coughs harshly, with more expectoration of thick, tenacious mucus, and 
more decided moist rales in the chest. The partial rel.ef thus gained usu- 
ally continues through the fore part of the day, and in some instances 
until eight or nine o'clock in the evening. But all the more severe symp- 
toms return at night and pursue the same course as dur : ng the preceding 
night and morning. It" not interfered with by appropriate treatment, the 
same series of phenomena usually continue from two to seven days, when 
all the more distressing symptoms rapidly disappear, coincident with a 
critical evacuation either through the skin, kidneys, or bowels, which 
leaves the patient enfeebled but comfortable. In the second group of 
cases there are no recognizable symptoms during the warm months of 
summer except an unusual tendency to catarrhal congestion in the nostrils 
on slight exposures to currents of air, or sudden atmospheric changes. 
But during the cold, wet and changeable weather of the latter part of 
autumn the regular paroxysms are usually ushered in by the same symp- 
toms as an ordinary attack of influenza. There are rigors, followed by 
moderate general fever, dull pains in the head and back, stuffing of the 
nostrils, and slight soreness of the throat. In two or three days the febrile 
symptoms have disappeared and the catarrhal irritation in the nostrils is 
subsiding, but as night comes on the patient feels a sense of tightness 
with slight dry wheezing in his chest, and a little disposition to cough. He 
retires at the usual time but has hardly become unconscious in sleep, be- 
fore he is aroused by dyspnoea and all the symptoms described as charac- 
terizing the paroxysms in the first group of cases. The asthmatic part of 
the difficulty having thus begun, usually continues in some degree 
throughout the whole of the cold season of the year. The dyspnoea and 
dry rales are pretty uniformly increased during the first half of the night, 
but lessened with more moisture toward morning, ending in considerable 
coughing and mucous expectoration in the morning; and usually after the 
first week or two the patient is able to be up and attending to some work 
or business during the day and suffering only moderately during the night. 
In some cases during the steady, dry cold of mid- winter all symptoms will 



412 ASTHMATIC BRONCHITIS. 

so far disappear as to allow the patient to appear quite well; but they are 
pretty uniformly renewed with more or less severity by every marked 
change involving' cold and damp air. In some cases, however, the disease 
is so severe and continuous that the patient is obliged to keep in-doors 
and be bolstered up in bed or sit in a chair every night during the cold 
season, unless he flees to a mild and dry climate. Cases belonging to this 
group may occur at any period of life, but you will meet with them far 
more frequently in patients over forty years of age than at an earlier 
period. Pathologically this group of cases would appear to consist of a 
mild grade of chronic bronchitis involving such a morbid sensitiveness of 
the bronchial nerves as to add the constricting iufl ences which cause 
the distressing dyspnoea that so torments the patient and robs him of rest 
at night. In the third group of cases the patients usually present no 
symptoms of irritation or trouble of any kind in the air passages, in the 
interval between the attacks. But suddenly, at some particular time each 
summer, they are attacked with coryza or symptoms of simple irritation of 
the Sehneiderian membrane. In from one to three days this subsides, but 
coincident with such subsidence the patients begin to feel the sense of 
tightness in the chest which soon culminates in a full paroxysm of dyspnoea 
with all the symptoms mentioned in describing the paroxysms in the first 
group of cases. The regular increase of all the symptoms at night pre- 
vents the patients from taking the recumbent position, robs them of all 
restful sleep, and causes a great sense of weariness and inability to make 
much effort to be up or out i uring the day. When once begun, the 
natural tendency of all of this class of cases is to continue from one to 
three months, or until the frosts of autumn appear. You will not fail to 
notice that the distinguishing features of all cases belonging to this group, 
are their strict periodicity, their commencement in the summer, and their 
definite self-limited duration. 

Diagnosis. — The cases belonging to all the groups I have described are 
distinguished from the other varieties of bronchitis by the distinct 
paroxysmal character of the phenomena, the apparently spasmodic quality 
of the dyspnoea, and the little tendency to muco-purulent expectoration 
or the accumulation of inflammatory products in the bronchial membrane. 
From pneumonia, pulmonary oedema, tuberculosis, and pleuritic effusions, 
they are distinguished by the predominance of dry wheezing rales, pro- 
longed expiratory acts, and the absence of both increased vocal fremitus 
and dullness on percussion. From pulmonary emphysema they are dis- 
tinguished by the paroxysmal character of the dyspnoea and its temporary 
duration, whde that ot emphysema is more continuous and generally 
permanent. 

Prognosis. — None of the cases belonging to the class of affections now 
under consideration are liable to terminate fatally unless they become 
complicated with other more dano-erous forms of disease. Indeed, many 
of the cases affected with annually recurring attacks of asthmatic bron- 
chitis have lived beyond three score and ten years. 

Treatment. — As the cases belonging to the first and second groups are 
pathologically similar to the milder grades of catarrhal and rheumatic bron- 
chitis,with the addition of irritation of the muscular fibers of the smaller bron- 
chi causing their contraction, so you will find the treatment I have already 
explained as applicable to those varieties equally applicable in the cases 
belonging to the groups named; provided, you can add some element or 
influence that will more directly lessen the morbid sensitiveness of the 
nerves controlling the action of the muscular fibers and thereby relieve 
their spasmodic contraction. In the limited number of cases that are 



TREATMENT. 413 

distinctly connected with the rheumatic or gouty diatheses the nervous 
irritation is dependent on the retention in the blood of the same morbid 
material that causes local irritation in other parts of the fibrous structures 
of the body. Consequently the most speedy and effectual relief is to be 
obtained by combining; with the anti-rheumatic or anti-gout remedies some 
agents that will lessen the sensibility of the bronchial nerves, and there- 
by lessen the constriction. In many of the rheumatic cases I have seen very 
great relief obtained by simply adding to the treatment I have already 
advised for rheumatic bronchitis a simple dose composed of from three 
to five decigrams (gr. v to viii) of sulphate of quinia and fifteen milligrams 
(gr. :j) of codeia, between eight and nine o'clock each evening. In cases 
complicated with the gouty diathesis I have found no combination more 
promptly beneficial than the bromide of lithium and wine of colchicum, 
as in the following formula: 

fy Lithii Bromidi, 20.0 grams 3v 

Vini Colchici Radicis, 20.0 c. c. 3v 

Elixer Sinplicis, 120.0 c. c. ^iv 

Mix. Of this four cubic centimeters (fl 3i) may be given every three, four, 
six h< 
bowels. 



or six hours until relief is obtained or the colchicum begins to disturb the 



In a large proportion of the cases belonging to the second group, as 
previously described, the combination of bromide and iodide of potassium 
with the fluid extract of the grindelia robusta and stramonium will afford 
much relief. The following is a convenient formula: 



Potassii Bromidi, 


25.0 grams 


3vi 


Potassii Iodidi, 


15.0 grams 


3iv 


Extracti Grindelias Fluidi, 


60.0 c. c. 


|ii 


Tincturas Stramonii, 


15.0 c. c. 


3|v 


Elixir Simplicis, 


45.0 c. c. 


§iss 



Mix. Of this four cubic centimeters (fl. 3') m ^y be given in a little 
additional water every four or six hours, until some relief is obtained, 
after which it may be continued three times a day until the relief is more 
complete. In many of these cases the addition, to this treatment, of a 
single powder of sulphate of quinia and codeia at nioht, will give much 
better rest, without inducing unpleasant secondary effects. In some of 
these cases, the formula I have already given you during the present 
hour, containing muriate of ammonia with small quantities of antimony 
and morphia, may be substituted for that containing the bromides and 
iodides, continuing to use the quinia three times a day. without the 
codeia. Some writers strongly recommend the use of morphia by hypo- 
dermic injection, either alone or in conjunction with chloral hydrate by 
the stomach.* 

There is no doubt about the efficac} 7 of the hypodermic injection of the 
sulphate of morphia, in temporarily relieving the paroxysms of dysp- 
noea; but very great caution is required in its use in all such cases. 
When the patient has already been laboring under the dyspnoea several 
hours and the blood is consequently impregnated with an excess of the 
retained carbonic acid gas, the quick development of the narcotic influ- 
ence of an ordinary hypodermic injection of the sulphate of morphia, not 

* See Practice of Medicine, by Bartholow, p 420. 



414 HAY-ASTHMA. 

only affords prompt relief to the dyspnoea, and induces sleep, but co- 
operating with the depressing qualities of the retained carbonic acid gas, 
there is great danger of so far paralyzing the respiratory function that 
death will follow in a few hours. Two such cases have come to my 
knowledge in this city, during the past year. Both were supposed to be 
laboring under simple severe paroxysms of catarrhal asthma, to which 
they had been subject, when the attending physician gave not more than 
fifteen milligrams (gr. 4) of morphia hypodermically. In each case the 
breathing soon became easier and sleep followed. In a little while the 
patients began to breathe more heavily, and to make no response to efforts 
to arouse them, and died in from six to eight hours. 

I have known similar results to follow in some cases of delirium tre- 
mens, in which liberal doses of chloral hydrate had been given, until the 
system was well supplied with it, and yet not controlling the nervous 
agitation and morbid vigilance, a hypodermic injection of morphia was 
resorted to by the attending physician, with the effect of speedily induc- 
ing a sleep from which there was no awaking. It is my duty to caution 
you, therefore, against resorting to hypodermic injections of morphia or 
other active opiate preparations when the blood is already imperfectly 
decarbonized from existing dyspnoea, or impregnated w T ith previous lib- 
eral doses of other narcotics or anaesthetics, lest the sudden development 
of the additional effect of your hypodermic should carry the suspension 
of nerve sensibility one step too far, and fatally paralyze the respiratory 
movements. 

In the treatment of the third group of cases, or those popularly called 
hay-asthma or hay-fever, a great variety of remedies have been tried with 
but little apparent benefit. In some cases that have come under my 
observation during the last few years the usual annual attack has been 
prevented, and in others rendered very mild, by commencing the use of 
quinine two weeks before the time for the expected attack, giving from two 
to three decigrams (gr. iii to v) morning and evening during the first w T eek, 
and the same doses three times a day during the second and third weeks, 
or until one full week after the time the attack had usually commenced. 
At the same time with the use of the quinine internally, the patients have 
been required to inhale through the nostrils three or four times a day, the 
vapor of the oil of eucalyptus globulus from a small vial which they could 
carry in their pockets. The number of cases thus treated for the purpose 
of preventing an attack is not large enough to test the real value of the 
plan; but so far as it has been faithfully tried it has proved positively 
beneficial. Of course, in all these cases, due attention was given to the 
regularity of the digestive organs and the excretory functions of the skin 
and kidneys. After the patient has passed one week beyond the regular 
time for the attack to commence, without its recurrence the use of the 
quinine may be diminished to thirteen centigrams (gr. ii), morning and 
evening, and one week later to only one dose every morning. But the 
inhalation of the vapor of the eucalyptus should be continued two or 
three times a day until the season for the active prevalence of the disease 
is passed. Instead of inhaling the vapor of the eucalyptus oil, others 
have used with supposed benefit free washing of the nostril with a solu- 
tion of sulphate of quinia, every morning and evening, for the purpose 
of destroying the germs which are supposed to impinge on the Schnei- 
derian membrane and to be the active agents in producing the disease. 

On the same theory of causation, one man is reported to have prevented 
the return of his usual attacks by constantly wearing a gauze veil over 
his mouth and nostrils. When preventive treatment has been neglected 



TREATMENT. 415 

or lias proved unsuccessful, and an attack has already commenced, I have 
seen much relief obtained by the use of a mixture of the fluid extracts of 
the grindelia robusta, the eucalyptus globulus, and tincture of stramo- 
nium, with bromide of. potassium as in the following formula: 

i$ Potassii Bromidi, 25.0 grams 3vi 

Extracti Grindeliae Robusta3 Fluidi, GO.O c. c. |ii 

Extracti Eucalypti Globuli Fluidi, 60.0 c. c. |ii 

Tincturae Stramonii, 15.0 c. c. 3iv 

Mix. Four cubic centimeters (fl. 3i) of this mixture may be given 
every four or six hours, in a little sweetened water; and in addition from 
two to three decigrams (gr. iii to v) of sulphate of quinia each morning 
and evening. When much dyspnoea has supervened, fifteen milligrams 
(gr. J) of codeia or morphia may be added to the evening dose of the qui- 
nine. In the early stage, while the membrane lining the nostrils is con- 
gested, presenting the ordinary symptoms of coryza, the nostrils should be 
rmsed every morning with a solution, either of quinine, carbolic acid, or ben- 
zoate of sodium, and the vapor of the oil of eucalyptus inhaled frequently 
during the day. In many cases, the patients obtain much temporary relief 
from smoking pastiles or cigarettes made of stramonium leaves previously 
soaked in a solution of nitrate of potassium. When, as sometimes hap- 
pens in the night, the paroxysms of dyspnoea become very distressing, 
and the means already mentioned fail to afford relief, the temporary and 
cautious inhalation of either ether, chloroform, or nitrite of anryl may be 
resorted to. In some of this class of cases you will find a degree of sore- 
ness in the chest and feverishness indicating a more decided inflammatory 
action in the bronchial membrane. In such, the formula I have given you 
containing muriate of ammonia (see page 406) should be given in place of 
that containing the grindelia robusta, or from six to ten decigrams (gr. x 
to xv) of iodide of potassium may be given dissolved in the syrup of gly- 
cyrrhiza three times a day. Many other remedies have been tried and rec- 
ommended by different parties in the treatment of this disease, but they 
all generally fail to do more than palliate the more distressing symptoms 
until the season for the continuance of the disease has passed when it 
ceases spontaneously, leaving the patient much impaired in strength, both 
of body and mind; but from which he recovers in a few weeks, with the 
assistance of plain food, pure air and moderate exercise. 

Prophylaxis. — From the fact, developed by common observation and 
confirmed by the investigations of Dr. Morrell Wyman and others, that 
this variety of disease prevails only in certain districts of country and at 
masons of the year when vegetation is well developed, and does not pre- 
vail in other locations, it has generally been supposed to originate from 
the inhalation of fungi, or the pollen of flowering grasses floating in the air. 
But whether the disease is caused by these, or by the organic germs dis- 
covered by Helmholtz, or by neither, the important fact remains, that 
large districts of country are entirely exempt frorti the prevalence of the 
disease. And consequently the most certain of all the prophylactic 
measures is for the susceptible parties to resort to some one of these local- 
ities during the season of the liability to an attack, or still better to make 
such locality their permanent place of residence. In our country the 
places of non-prevalence of this disease embrace the mountain districts of 
New Hampshire, Vermont and New York, continuing with the Allegheny 
range southward to its termination in the Southern States; also the island 
of Mackinaw, Marquette, and all the territory around Lake Superior; to- 



416 PNEUMONIA. 

gether with the great mountain ranges stretching from Dakota to the ta- 
ble lands of Western Texas, and the western or Pacific slope of the Sierra 
Nevadas. In almost any part of these elevated regions and in some more 
limited districts not elevated, the sufferer from bronchial asthma or hay- 
fever may obtain entire exemption, either by a temporary resort during 
the season of his liability to an attack or by a permanent residence. 



LECTURE XLIII. 



Pneumonia— Its History, Causes, Sjnnptoms, Pathological Anatomy, Diagnosis and Prognosis. 

GENTLEMEN: The disease to which I invite your attention during the 
present hour, is one of the most important inflammatory affections 
that you will meet in your ordinary fields of general practice. By pneumonia 
is meant an inflammation of the parenchyma of the lung. Descriptions of 
the disease, more or less accurate, are to be found in the earliest records 
of medical literature, although it was not clearly differentiated from 
bronchitis and pleurisy until the beginning of the present century. By 
many of the early writers it was called peri-pneumonia, by others 
malignant pleurisy, bilious pleurisy, and when complicated with 
capillary bronchitis, peri-pneumonia notha. By Dr. Gallup, in his history 
of the epidemics of Vermont from 1800 to 1815, and by other early New- 
England writers, the disease is often called malignant pleurisy, peri- 
pneumonia, and pneumonia typhoides. From these writers it would appear 
that the disease was not only of frequent occurrence in. the latter part of 
winter and early spring, but in some localities assumed a very 
malignant and fatal character. At the present time it is generally called 
pneumonia, pneumonitis, or pneumonic fever. By most writers two 
varieties are recognized, namely, the croupous and the catarrhal. The 
first name is used to designate such cases as attack the parenchyma of 
the lung primarily, and the second, such as are complicated with or are 
secondary to the symptoms of bronchitis. When the inflammation attacks 
a section of the lung it is called lobar pneumonia; when it invades 
separate lobules, either primarily or by extension from the smaller bronchi, 
it is called lobular or disseminated pneumonia; and if the latter continues 
in a chronic form it is generally called interstitial pneumonia and some- 
times fibroid phthisis or pulmonary sclerosis. When it has prevailed in 
malarious districts, and the accompanying fever has shown distinct ex- 
acerbations and remissions it has been styled bilious pneumonia or lung 
fever. 

Etiology. — The prevalence of pneumonia is influenced by climate, 
season of the year, occupation and habits, age, sex, and previous condition 
of health. The statistics presented by Dr. Samuel Forrey in his work on the 
climate of the United States, to which I have referred in previous lectures, 
appeared to show that pneumonia was most prevalent, and caused the 
highest ratio of mortality, in what he called the middle climatic belt, w T hich 
embraces that part of our country lying between the thirty-third and the 



CAUSES. 417 

thirty-ninth parallels of latitude, and extending from the Atlantic coast to 
the eastern slope of the Rocky Mountains. It is in that belt of country 
that you find long continued and high summer heat, and though the 
winters are short they usually embrace one or more perio Is of intense 
cold, which gives the thermometric combination of long and warm sum- 
mers, short and cold winters, and a wide range between the warmest days 
of summer and the coldest days of winter. Other circumstances being 
equal it was where these characteristics were most marked that he found 
attacks of pneumonia to occur numerically most frequent and to prove 
most fatal. It must be remembered, however, that the statistics compiled 
by Dr. Forrey, and to some extent re-produced by Dr. Drake in his work 
on the topography and diseases of the Interior Valley of the Continent, 
relate exclusively to adult males, as represented by soldiers and officers 
in the United States army. And while this makes the conditions lor 
comparison in some respects more uniform, yet the liability of soldiers to be 
frequently changed from one place to another, and the absence of both chil- 
dren and old persons, may cause the result to be somewhat different from 
what it would be if the comparison could be based on equally correct statis- 
tics of the sickness and mortality in a resident population of all ages and 
both sexes. The statements made by standard writers in regard to the 
effects of climate on the prevalence and mortality of pneumonia are very 
general and in some respects contradictory. Thus one of the latest writers 
on practical medicine says: u Its prevalence is extensive over the globe, 
and it is found nearly alike in all latitudes." * Another simply remarks 
that " it occurs in ail degrees of latitude, under every variety of climate, 
and at all ages." f 

These expressions would lead you to suppose that climate exerted little 
or no influence over the prevalence of the disease. On the other hand, Drs. 
Drake and Flint represent the disease as much more prevalent and fatal 
in the Middle and Southern States than in the Northern. The latter 
says: "In this country the disease occurs in the Middle and Southern 
much oftener than in the Northern States."]; You will be able to judge 
better of the value of these general statements, and also concerning the 
differences between statistics exclusively from military posts compared 
with those from large cities with their mixed and dense populations, by 
the following figures relative to the ratio of mortality from pneumonia in 
the cities of Chicago, New Orleans and San Francisco for the year 1882, 
derived from the official reports of the health officers of the cities named : 
The whole number of deaths from pneumonia in Chicago in 1882, as re- 
ported from the health office, was 782; that is, 1 for every 645 of the 
entire population, as given in the census of 1880. The whole number 
reported in New Orleans for the same year was only 203, or one for every 
1088, of the population as .given by the same census. The whole num- 
ber of deaths from pneumonia reported in San Francisco, during 1882, 
was 452, which makes one death to every 518 of the population. Lest 
there should have been some extraordinary or unusual prevalence of the 
disease in Chicago in 1882, I extended my examination of the records to 
three consecutive years, and found the average ratio of deaths from pneu- 
monia for the years 1880-1-2, to have been one in 765 of the whole pop- 
ulation. You thus see that the actual mortuary statistics show a very 
decidedly greater prevalence of pneumonia in this city, representing the 

* Pee Science and Practice of Medicine, Vol, II., p. 204. 1882, bv A. B. Palmer, M. D., etc. 
tSee Practice of Medicine, p. 325, 1881. By Roberts Bartholow, M. D. 
t See Practice of Medicine, p. 168, ItSl. By Au-tin Flint, M. D. 

27 



'418 PNEUMONIA. 

northern part of the great interior valley of our country than in New Or- 
leans, which represents the southern part of the same valley. Without 
taking time to work out the details, I have extended the examination far 
enough to show that the same results would appear if the comparison 
should be extended to the cities of Buff do, New York and Boston, in 
contrast with Mobile, Jacksonville and Charleston, as representing the 
north-eastern and south-eastern parts of our country. 

A similar examination of such official returns as are within my reach 
concerning the mortality from pneumonia in the cities of Washington, 
Cincinnati and St. Louis, representing the middle belt or zone, as de- 
scribed by Dr. Forrey, appears to show a slightly larger ra io of deaths 
in proportion to the population than the cities of the northern belt. The 
difference, however, is not great. From such fragmentary facts as I have 
been able to gather from reports on epidemics and on the prevalence of 
acute diseases, made to the American Medical Association and to several 
of the State medical societies, I think the same relative ratio of mortality 
from pneumonia exists in the country districts of the Northern, Middle 
and Southern belts as in the cities I have named. While it is true, there- 
fore, that pneumonia prevails to some extent over a large part of the in- 
habited portions of the globe, it is nevertheless influenced very much by 
climate; being more prevalent and causing a higher ratio of mortality 
in the middle and northern parts of the United Spates than in the south- 
ern. The same rule applies to the Pacific slope, embracing the States of 
California and Oregon, which are represented by some writers as enjoying 
a singular immunity from the disease;* while the statistics of mortality 
in San Francisco for 1882, as I have already stated to you, show a higher 
ratio of mortality from it, than either Chicago or New Orleans. The fact 
that pneumonia is more prevalent in cold than warm climates is corrobo- 
rated by the influence of season of the year. 

Seasons. — Of the 782 deaths from pneumonia in Chicago in 1882, 295 
occurred during the first quarter, 246 during the second, 83 during the 
third and 158 during the fourth. Of the 203 deaths reported in New Or- 
leans for the same year, 86 occurred during the first quarter, 58 during 
the second, 35 the third and 24 the fourth. In San Francisco for the 
same year, of 452 deaths from this disease, 225 occurred during the first 
quarter, 108 the second, 44 the third and 75 the fourth. 

From these figures it appears that about two- thirds of all the deaths 
occur during the first six months of the year, and that the causes of the 
disease reach their highest degree of activity about the middle or climax of 
the winter season, and continue active until the beginning of summer. 
From a table giving the number and causes of deaths in the city of 
Memphis in 1852, I learn that the number of deaths from pneumonia was' 
26. The population was then estimated to be 12,000, which would be 1 
in 461 of the population. Of the 26 cases 12 occurred during the first 
quarter, 4 the second, none the third, and 10 the fourth. \ 

The statistics derived from the various military posts give the highest 
ratio of attacks during the first quarter, while in some places the next 
highest was in the second and others in the fourth; but all agree in giving 
the lowest ratio of both cases and deaths in the third quarter, composed 
of July, August and September. Throughout the countries of Europe 
the same influence of the seasons is observable as in this country. J 

Occupation and Habits. — Pneumonia is undoubtedly more frequently 

*See Reynolds' System of Melicine, American edition, Vol. II, p. 154. 
fSee Transactions ot the American Medical Association, Vol. VI, p. 826, 1853. 
J ;ee Reynold's System ol Medicine, American edition, Vol. II, p 155. 



CAUSES. 41 ( J 

mot with among those classes whose occupations cause them to be most 
exposed to the vicissitudes of the seasons, and are scantily supplied with 
the moans of protection. . In the Southern States the colored population 
Buffer in a greater ratio than the white, especially in the plantation 
districts. The same is true concerning the Mongolians in San Francisco, 
and the poorer laboring classes of the foreign population in all the 
Northern cities. Personal habits also exert an important influence. 
Living and sleeping in overcrowded apartments; wearing insufficient 
clothing to protect the surface from sudden and severe atmospheric 
Changes; and more than all, the free use of alcoholic drinks. The latter 
act directly by impairing the vasomotor nerve influence and lessening the 
efficiency of the processes of disintegration and elimination, and indirectly, 
by leading those under their excessive influence into severe exposures, 
while the power of vital resistance is impaired. 

Age. — You will find cases of pneumonia occurring at all periods of life. 
But as might be inferred from what I have just said about the influence 
of occupations and habits, it occurs more frequently in the middle period 
of adult life, that is, from twenty to forty years of age than either earlier 
or later in life. The next periods most liable to attacks are those of in- 
fancy, or under five years and over sixty. 

Sex. — The same circumstances that determine the attacks to occur more 
frequently among the most exposed part of the adult population, also 
operate to render the attacks more frequent in men than in women, in 
the ratio of two or three to one. This applies, however, chiefly to the 
cases occurring during the active period of adult life; the excess among 
males being much less in early childhood than at the subsequent periods. 

JPi'evious Condition of Health. — You will see it stated by some writers 
that pneumonia attacks the vigorous and healthy more frequently than 
the infirm. This opinion has doubless arisen from the fact that it is chiefly 
the vigorous and healthy who engage in such occupations as subject them 
to the exposures and hardships most likely to induce attacks, while the 
weaker and more delicate seek less severe work and better protection. If 
both classes were subjected to the same degree of labor and exposures, 
there is no doubt but the weaker would give a much higher ratio of at- 
tacks than the more robust. And yet, with the exception of pulmonary 
tuberculosis, I have not been able to see any special predisposition to 
attacks of pneumonia during the progress of other diseases or constitutional 
cachexies. That the presence of primary tubercular deposits greatly 
favors the development of pneumonic inflammation in the tissues sur- 
rounding such deposits, I have no doubt. 

Exciting Causes. — Many cases of pneumonia occur without any appar- 
ent exciting causes. Many other cases are traceable to exposure to cold 
currents of air upon limited parts of the surface, or to such protracted 
severe cold as to chill the whole body and depress the vasomotor 
influence over the systemic circulation. Severe exercise in the face of 
strong cold winds is very liable to provoke an attack. In advanced life, 
after the cartilages of the ribs have become bony and the frame work of 
the chest less movable, all severe physical exercise is more liable to be 
followed by pneumonic inflammation. Some fatal cases have occurred in 
such persons under my own observation, directly induced by unusual run- 
ning to reach a railroad depot before an expected train should pass. 
There is no tangible evidence that pneumonia is caused by any specific 
materies morbi, whether organic or inorganic. On the contrary, its 
occurrence, to some extent, in all civilized countries and at all seasons of 
the year, yet being markedly influenced in the degree of its prevalence 



420 PNEUMONIA. 

by both climate and season, its frequent association with pleurisy on the 
one side and bronchitis on the other, its constant variations in the 
amount of lung tissue involved, being in a large majority of cases uni- 
lateral, and in most of them con fined to one or two lobes, and its entire 
exemption from the law that one attack destroys the susceptibility to 
subsequent attacks, render the question of its dependence on any one 
specific exciting cause highly improbable, and give it much more fully 
the characteristic of an acute local inflammation, than of a general febrile 
disease. 

Symptoms. — The symptoms and progress of pneumonia vary in some 
degree from the varying circumstances under which it occurs. In most 
cases of acute lobar pneumonia the attack commences with a chill or 
chilliness simultaneously with a dull or deep seated pain in one side of 
the chest, and sense of oppression or difficulty in breathing. The cold- 
ness soon gives place to increased heat; redness of the face; shorter and 
quicker breathing; increased pain or sense of oppression in the chest, 
with some cough. The pulse becomes more full and frequent; the urine 
less in quantity but containing an excess of urea and a deficiency of the 
chlorides; and bowels quiet. In many cases there is pain in the fore- 
head increased by the jar of coughing, and aching pains in the 
back and limbs. At first the cough is moderate with little or no 
expectoration; but it increases in depth and frequency and during the 
second day there is more or less expectoration of a thick mucus, which 
increases during the third and fourth days and usually becomes intimately 
intermixed with blood, constituting the "rusty spu a" mentioned in all 
your works on practice, as characteristic of pneumonic inflammation. All 
the general febrile symptoms, together with the local pain and oppression 
in the chest, continue to increase until the climax is reached, usually be- 
tween the beginning of the fourth and the end of the sixth days. At that 
time you will generally find the face still somewhat flushed, expression 
dull, mind often wandering, especially during the night, respirations short 
with diminished expansion of one or both sides of the chest, pulse frequent, 
soft, and in some cases decidedly weak, cough frequent with pretty free 
bloody expectoration, and a temperature between 39.5° and 41.6° 0. (103° 
and 106° F.). If the inflammation has involved the whole of one lung or 
a large part of both, the diminished oxygenation and decarbonization of 
the blood may cause the flush on the face to appear purplish or leaden in 
color, the mind to be more dull and drowsy, some coarse mucous rales in 
the chest, with very imperfect expansion, and a weak, variable pulse. In 
cases progressing unfavorably the drowsiness and mental wandering in- 
crease, the expectoration shows less blood and more intermixture of pus, 
the breathing becomes more oppressed, with increasing difficulty in clear- 
ing the bronchial tubes of the constantly accumulating muco-purulent 
exudation, the cardiac impulse and the whole circulation diminish rapidly 
in force, and finally the surface becomes covered with a clammy sweat, the 
discharges become involuntary, the larynx and trachea move up and down 
at every inspiration and expiration, the chin soon drops, the breathing 
becomes very frequent and noisy, and life ceases, more frequently between 
the sixth and ninth days from the beginning of the attack. In cases pro- 
gressing more favorably, after reaching the climax of both general and 
local symptoms between the third and fifth days all the more prominent 
symptoms remain nearly stationary one or two days, after which the tem- 
perature rapidly declines, the expectoration contains less blood, changing 
first to a tawny or reddish yellow, and subsequently to an opaque or muco- 
purulent appearance and easily dislodged by coughing, the soreness and 



SYMPTOMS. 421 

oppression rapidly diminish, the pulse becomes slower and more natural, 
and the secretions more free. These changes take place so rapidly that, 
in the milder cases, convalescence is established in from seven to nine 
davs from the initial chill, while in the more severe the same result is not 
reached in less than from eleven to fourteen days. Thus far in the clin- 
ical history of the disease I have directed your attention to such symptoms 
as you may observe without special physical exploration, but the additional 
knowledge to be obtained concerning the existence, extent, and stage of 
progress of pneumonia, by proper auscultation and percussion, is of such 
importance that these methods of investigation should never be neglected. 
Immediately after the initial chill and during the first stage of the inflam- 
matory process, auscultation over the affected part of the chest readily 
detects a fine, dry, crepitant rale, rather suddenly and sharply developed 
in the last part of the act of inspiration and ceasing with the beginning 
of the expiratory act. At the same time and place there is slightly in- 
creased fremitus of voice and a shade less than the natural resonance on 
percussion. In from twenty-four to forty-eight hours in most cases the 
fine crepitant rale begins to diminish, giving place to a sub-mucous or 
moist rale with still more vocal fremitus and more decided dullness on 
percussion. These physical signs continue rather to increase until the 
climax of the disease, between the fourth and seventh days, accompanied 
by an increasing amount of coarse, mucous ronchus. If the case progresses 
unfavorably the same dullness on percussion, increased vocal fremitus, 
and coarse mucous ronchus continue until the fatal result. But if the 
tendency is to recovery, in one or two days after reaching the climax the 
dullness and vocal fremitus begin to diminish, and finally disappear with 
the establishment of convalescence. You perceive that the fine crepitant 
rale is coincident with the stage of simple engorgement of the pulmonary 
capillaries and consequ°nt pressure upon the alveoli or air cells, and that 
it disappears as the exudation progresses, filling up the alveoli and inter- 
stitial spaces instead of simply compressing them, while the vocal fremitus 
and dullness from percussion, only slight during t e stage of engorgement, 
become decided and well marked as characteristic of the stage of exuda- 
tion and solidification, and gradually disappear during the stage of resolu- 
tion. In some cases the crepitant rale reappears for a brief time at a cer- 
tain stage of the process of resolution, and is then called "crepitus re- 
dux." By carefully noting these physical signs from day to day, in con- 
nection with the ordinary symptoms, you will be able to attain a very 
accurate knowledge both of the extent and stage of progress of the in- 
flammation in any given case. 

Malarial Influences. — Having detailed to you the more important 
symptoms and physical signs of the ordinary typical eases of acute lobar 
pneumonia, I must remind you of certain important deviations from this 
standard, that you are liable to meet with more or less frequently. For 
instance, >ii strongly malarious districts there are many members of the 
community who have, habitually, less than the normal quantity of red 
corpuscles and plastic elements in their blood, and the vital affinity or 
tonicity of whose tissues is below the standard of good health. It is well 
known that in all such communities pneumonia is apt to prevail more or 
less during the last half of winter and the early part of spring. Cases 
occurring under such circumstances are more uniformly ushered in by a 
decided chill, followed by a more rapid development of a high grade of 
fever, with more acute pain and sense of opp ession in the chest, more 
frontal headache, and early crepitant rale over a larger part of one lung. 
But the state of the blood and the properties of the tissues are both favor- 



422 PNEUMONIA. 

able to early and copious exudation. Consequently the decided dullness 
on percussion comes earlier with more copiously bloody expectoration 
and more oppressed breathing. In most of these cases the fever distinctly 
remits in the morning and exacerbates in the afternoon and first half of 
the night; and as it approaches its climax there is more delirium and a 
greater degree of exhaustion. A large proportion of these cases tending 
to recovery, terminate the general symptoms rather abruptly by critical 
evacuations from the skin, kidneys or bowels; after which the affected 
part of the lung clears up by resolution with remarkable rapidity. On 
the contrary, in cases progressing toward a fatal result, after reaching the 
climax of the exudative stage, the skin and eyes, in many, present a yel- 
low or jaundiced hue; the urine scanty and of a 1 eddish yellow color; 
pulse frequent, but soft and weak; mind dull or wandering; respirations 
short, with sudden fall of the abdominal muscles in expiration; cough 
frequent, and accompanied by copious reddish yellow expectoration con- 
sisting of muco-purulent material mixed with the red corpuscles, and 
indicating the existence of a diffuse suppurative process in the inflamed 
part of the lungs. Most of the cases presenting such symptoms, reach a 
fatal degree of exhaustion and the patients die during the second week 
of their progress. During the first ten years of my residence in this city 
(Chicago), while there was neither proper sewerage nor an adequate sup- 
ply of water from the lake, and malarious or periodical fevers were preva- 
lent in some degree during every summer and autumn, I saw many cases 
of pneumonia during the winter and spring seasons presenting all the 
modifications in symptoms and progress I have indicated. 

Typlioidal Influences. — In the more densely populated cities, manu- 
facturing towns, and long-settled country districts, where the sanitary 
conditions exist which predispose to the development of typhoid fever, 
diphtheria, etc., the attacks of pneumonia are characterized, generally, by 
a less marked chill at the commencement, less acute pain in the chest, a 
slow rise of temperature, a softer, weaker pulse, and a more dull, heavy 
expression of countenance. The first or congestive stage is usually short, 
exudation commencing early but progressing more slowly than in cases 
influenced by malaria, and generally giving rise to less blood in the ex- 
pectoration, but of a darker color: and when the crisis is passed, the proc- 
ess of re-absorption and removal of the exudative material goes on slower 
and sometimes less perfectly. In cases which are progressing unfavor- 
ably, about the end of the first week the pulse becomes more frequent 
and weak; respirations short and abdominal; the tongue and mouth dry; 
the mind dull and sometimes delirious; cough, and expectoration moder- 
ate in amount, but the latter dark or reddish brown color and consisting 
of muco-purulent matter mixed with dark blood; the intestinal evacua- 
tions thin and brown but not frequent, and usually by the middle or lat- 
ter part of the second week, the efforts at coughing do not clear the bron- 
chial tubes of the accumulating sputa; the coarse, moist rales increase 
over the whole chest, the lips and countenance show a leaden paleness, 
the pulse sinks to a mere thread, skin becomes wet with a cool sweat, and 
the patient dies. A large proportion of the cases of pneumonia which 
have occurred in this city during the last twenty years, have been of this 
grade. 

Rheumatic Pneumonia. — When speaking of bronchitis in a former 
lecture, I stated that rheumatic inflammation was liable to occur in the 
fibrous structure of the smaller bronchi, and sometimes to extend into the 
connective tissue of the lungs in a chronic form, and cause pulmonary 
sclerosis. I have also met with occasional cases of more acute rheumatic 



KHEUMATIC PNEUMONIA. 423 

inflammation primarily attacking the pulmonary structures, and constitut- 
ing- a dangerous and persistent form of pneumonia. I have seen one 
such case in consultation during the present winter. A man aged fifty 
years had been attacked two weeks previous to my visit with severe pain 
in the lower part of the right side of the chest, accompanied by some 
cough, shortness of breath, and general fever, with a fair degree of the 
fine crepitant rale and slight dullness on percussion. On the second day 
the crepitant rfile had ceased over the lower part of the right lung, giving 
place to a slight amount of sub-mucous rale and decided dullness on per- 
cussion, but the expectoration was scanty, tenacious and only tinged with 
blood. At the same time there was a line higher up over which the fine 
crepitant lale was very distinct, indicating an extension of the inflamma- 
tion upward. The same progress upward continued until the whole of 
that lung had been invaded and rendered dense from the exudation, 
giving all the physical signs of hepatization, and a temperature varying 
from 39° to 40.5° C. (103° to 105° F.). The inflammation then attacked 
the lower lobe of the left lung, and at the time of my visit was occupying 
more than half of that lung; the night previous the patient had been 
attacked with severe pain in the cardiac region, with great sense of op- 
pression in the whole chest, while the pulse was rapid, irregular, and weak. 
I found in addition to the physical signs of hepatization uver the whole of 
the right and more than half of the left side of the chest, plain en- 
docardial murmurs indicating active inflammation in the lining of the left 
cavities of the heart. The extremities were cool and purplish; the pulse 
frequent, irregular and soft; respirations short with moist rales and but 
little expansion of the chest; and mind wandering. He died about 
twenty-four hours later. No post mortem examination was allowed. 
Throughout the whole course of the disease, the expectoration had been 
tenacious mucus without pus, and only scantily mixed with blood; and the 
pain in the chest had been unusually severe and persistent. These facts, 
with the final development of endocarditis, and the further fact that the 
patient had been subject to occasional attacks of articular rheumatism 
for several years, left no doubt on my mind but that the present attack 
was one of subacute rheumatic inflammation of the parenchyma of the 
lungs. In other words a genuine rheumatic pneumonia. 

Catarrhal Pneumonia — Lobular, or Disseminated Pneumonia. — Lob- 
ular catarrhal pneumonia, as described by most writers, is a secondary 
affection, occurring in connection with capillary bronchitis, and is met 
with far more frequently in early childhood and in old age than at any of 
the intermediate periods of life. As the pneumonic inflammation in 
these cases results from either a direct extension of the inflammatory 
action from the bronchioles to the alveoli of the lung, or from a prior 
occlusion of the bronchi and collapse of the alveoli or clusters of cells, 
(atelectasis) involving capillary congestion and inflammation, it neces- 
sarily develops in the individual lobules, and not in a section of the lung 
as in lobar pneumonia. And as individual lobules may be involved 
leaving other lobules between them unaffected, such cases have given rise 
to the phrase ''disseminated pneumonia." So far as the inflamed lobules are 
concerned they pass through the same stages of congestion, exudation, 
hepatization, and resolution or suppuration, as occur in lobar inflamma- 
tion. The co-existence of capillary bronchitis in almost all of the cases 
of the lobular form of pneumonia, is well calculated to obscure some of the 
more important diagnostic symptoms of the latter. For instance, the mix- 
ture of dry and moist rales generally heard so readily over the greater 
part of the chest in capillary bronchitis, is so much more prominent than 



424 CATARRHAL PNEUMONIA. 

the fine crepitant rale of the pneumonia that tli3 latter is seldom dis- 
tinguished; while the separation of the affected lobules by the interven- 
tion of others not affected, causes the dullness on percussion and fremitus 
of voice to be less marked than in the second stage of ordinary lobar 
pneumonia. And .if the number of lobules involved is small, the 
pneumonic part of the disease may escape detection. Usually, however, 
the increased fremitus and diminished resonance, coupled with the dimin- 
ished expansion of the chest, shortness of the expiratory act, and the 
higher temperature, are sufficient to indicate the existence of the 
pneumonic complication, even if no rusty sputa are seen. 

Pathological Anatomy. — The very vascular and distensile character of 
the lung structure allows the ordinary anatomical changes which take 
place in the different stages of all inflamed tissues, to reach a high degree 
of development. The intense vascular engorgement of the first stage 
gives to the inflamed portion of lung a bright red color, with less crepi- 
tation between the fingers and less complete collapse. In the second stage, 
that of exudation and solidification, the redness is a shade darker, the crep- 
itation between the fingers and the tendency to collapse entirely lost, and 
the cut surface presents a red, granular appearance from which oozes a 
scanty amount of red frothy serum, mixed with blood from the larger 
severed vessels. Examined under the microscope the capillary vessels 
surrounding the alveoli are seen greatly distended and in many places 
obstructed by the corpuscular elements of the blood; while the alveoli 
and interstitial spaces of the connective tissue are filled with leucocytes 
or migrating corpuscles, liquor sanguinis, and more or less solidified fibrin 
and plastic elements of the blood. If death takes place during the third 
stage the inflamed portion of lung is less intensely red, a little less firm or 
hard to the feel, but still without crepitation or collapse under pressure. 
When incised the cut surface presents a lighter grayish color, less 
granular, and from it oozes a somewhat frothy sero-purulent fluid, with 
blood from the orifices of the severed blood-vessels. Examined more 
closely the cut surface in most cases is found to contain many small con- 
cavities or minute abscesses which have been laid open by the incision; 
while the miscroscope shows the alveoli and interstitial spaces still filled 
with inflammatory products but everywhere undergoing the process of 
purulent degeneration by which the leucocytes and proliferating cell 
elements have assumed the form of pus corpuscles. In some of the more 
highly plastic or phlegmonous grades of pneumonia the suppurative 
degeneration will be found confined to the more central part of the in- 
flamed structure, and the pus will have collected into one or more larger 
and more circumscribed abscesses. And in cases of still less frequent 
occurrence the vessels in a portion of the lung tissue have been so com- 
pletely obstructed by the accumulated inflammatory products, as to 
suspend all circulation in that part, and the post mortem examination 
reveals the existence of gangrene or death of the part, with diffuse sup- 
puration surrounding the slough. 

Diagnosis. — In giving \ ou the clinical history of the different grades 
and stages of pneumonic inflammation, I have pointed out so fully the 
ordinary symptoms and physical signs that characterize or serve to dis- 
tinguish, not only the disease itself, but also each stage of its progress, 
that it would be an unnecessary repetition to enumerate them again at 
this time. 

Prognosis. — The majority of recent writers represent lobar pneumonia, 
or pneumonitis, as a self-limited disease, of comparatively brief dura- 
tion, and in much the larger number of cases ending in resolution or spon- 



PROGNOSIS. 425 

taneous recovery. And these circumstances are claimed as evidence that 
the disease is a general zymotic fever instead of a mere local inflamma- 
tio i. Siu-h writers do not appear to have comprehended the fact that all 
acute local inihmmations are necessarily self-limited in their duration; 
ami that they pass through certain stages either to resolution and recov- 
ery or to destruction of the inflamed structures with more uniformity 
than any one of the general fevers. The special prognosis in all cases of 
pneumonia will be influenced by the age of the patient, his previous con- 
stitutional condition and tendencies, the extent of lung tissue involved, 
the special character of the inflammatory process, and the diseases with 
which it may be complicated. All other circumstances being the same, a 
much higher ratio of deaths will occur in children under five years, and 
in adults over fifty, than at any intermediate periods of life. This is 
probably owing to the fact that at the two extremes of life there is less 
vital resistance to the progress of any acute disease, and that a very large 
proportion of the cases occurring at these periods are complicated with 
general capillary bronchitis. When the disease attacks persons of a 
distinctly scrofulous or tuberculous diathesis there is a much greater 
tendency to early and diffuse purulent degeneration of the exudative 
material and consequently to a higher ratio of deaths. The same remark 
applies also to such cases as occur in subjects affected with constitutional 
syphilis. No one circumstance, however, exerts more influence over the 
rate of mortality than the extent of lung tissue involved in the inflamma- 
tion. Inasmuch as the oxygenation and decarbonizition of the blood 
(changes essential to the continuance of life) are directly dependent on 
the continuance of the supply of fresh air in the pulmonary alveoli and 
the proper movement of the blood around such alveoli, it is evident that 
whenever the products of pneumonic exudation occupy the alveoli, infun- 
d.buli and interstitial spaces of so large a part of the lung structure as to 
interrupt or greatly diminish the amount of these changes, the life of the 
patient will be lost or placed in great danger. But so long as the inflam- 
mation does not occupy decidedly more than one half of one lung, or only- 
one lobe of each lung;, there will be but little danger from the direct 
interference with the oxygenation and decarbonization of the blood; and 
if there are no complications with other diseases or unfavorable constitu- 
tional conditions, such cases will pretty uniformly recover under favor- 
able hygienic management alone. In cases of double pneumonia in 
which more thrin half of each lung is involved and filled up with the in- 
flammatory products, death usually results from apncea before the third 
stage of the inflammatory process is reached. When the disease is uni- 
lateral, though involving the whole lung, or double, and involving only 
a little less than one half of each, the patients will not usually die directly 
from apncea or the exclusion of air; and yet the interchange of the car- 
bonic acid gas for oxygen as the blood passes through the pulmonary 
vessels will be so much diminished that the blood passes into the left cav- 
ities of the heart and is sent through the whole arterial system in a con- 
dition which renders it incapable of maintaining the full activity of the 
nervous and secretory structures generally. Consequently the patient's 
mind becomes dull or wandering; his countenance dingy; his pulse fre- 
quent and soft or weak; cardiac impulse diminished; moist rales in- 
crease in the chest; the surface relaxes and the skin becomes covered 
with perspiration; and a little later the sphincters relax, allowing invol- 
untary discharges and death. The latter takes place, in most of these 
cases, during the second week after the commencement of the attack, and 
is very generally attributed to asthenia or cardiac weakness. But what 



426 PNEUMONIA. 

causes the asthenia? Plainly, just two factors. First, the imperfect oxy- 
genation and decarbonization of the blood, as just described; and second, 
the diversion of three or four pounds of blood from the general circulation 
and its lodgment as exudative material in the alveoli, infundibuli, bron- 
chioles, and interstitial spaces of the connective tissue of the inflamed 
part of the lungs, constituting a form of depletion very much more 
dangerous to the patient than the loss of one or two pounds by venesec- 
tion to relieve the vascular engorgement of the first stage of the morbid 
process. 

Another circumstance which exerts an influence on the prognosis is the 
special character of the inflammation as determined by the nature of the 
predisposing causes and sanitary surroundings of the patient. You may 
regard it as a general rule, that th > presence of all such causes as favor 
the development of a typhoid or asthenic condition; or of the active prev- 
alence of the malaria that causes periodical fevers; or of any special 
epidemic influence, will increase the ratio of mortality from pneumonic 
inflammation. The same is true in regard to such cases of pneumonia as 
occur in individuals already laboring under any one of the general febrile 
affections, or any serious disease of the heart or kidneys. Pneumonia is 
not a very infrequent complication of such cases of typhoid, malarious and 
eruptive fevers as occur during the cold and changeable seasons of the 
year. Measles and whooping-cough are particularly liable to become 
complicated with the pulmonary inflammation. And in all such cases, as 
well as in those that occur in connection with organic diseases of the 
heart, there is greater danger of a fatal termination than from an equal 
extent of pneumonic inflammation without the co-existence of other dis- 
eases. 

From the foregoing observations you will readily infer that the statis- 
tics given by different writers concerning the ratio of mortality from pneu- 
monia are of very little \alue unless accompanied by the facts concerning 
the various modifying influences to which I have referred. 



LECTURE XLIV. 



Pneumonia Continued— Its Treatment. Chronic Pneumonia— Its Symptoms, Pathological 
Anatomy, D agnosis and Treatment. 

GENTLEMEN: You will find in the text books and literature of the 
profession many and widely differing methods of treatment for 
pneumonia at different times, and by different writers at the same time. 
You will find among these, the method by blood-letting, by antimonials, 
by mercurials, by expectation, by alcoholics, by sulphate of quinia, by cold 
affusion or the pack, and by nothing except rest and nourishment. You 
will see each of these methods discussed, not in regard to their appli- 
cability to particular cases and stages of the disease, but in comparison 
with all the other methods, as special modes of treatment applicable to all 
cases alike. And as nearly all the cases of uncomplicated unilateral 
pneumonia tend to recovery the advocates of each method make a fair show 



TREATMENT. 427 

of success. And when one like M. Barthez, in his paper presented to the 
French Academy of Medicine in 1862, on the expectant treatment of 
pneumonia in children, skillfully eliminates from his statistics all lobular, 
pseudo-lobar, catarrhal, and broncho pneumonic cases, together with 
such as occur in the progress of other diseases, it is not surprising that 
he should report the extraordinary ratio of only one death in 106 cases.* 
By such a course nearly all the cases involving any danger to life are set 
aside, and of course those remaining to be reported on, ought to recover 
under any treatment not positively detrimental. If the statements I 
made to you in the thirty-third lecture of the present course, concerning 
the fixed and variable elements of the inflammatory process, and the 
modifications the latter are capable of inducing are correct, as well as the 
views presented in the lecture of yesterday concerning the modifying in- 
fluence of different causes on the character and results of pneumonia, you 
can not fail to recognize the inutility of attempting to treat all cases of 
the disease by any one method or by the same remedial agents in the 
different stages of its progress. On the contrary, the special objects to be 
accomplished or indications to be fulfilled in the treatment of pneumonia, 
vary with each successive stage in the progress of the inflammation. In 
the first stage, characte ized by increased excitability of texture and in- 
tense engorgement and distension of vessels, the plain indications are to 
allay the excitability and lessen the vascular fullness; and in the same 
ratio that you succeed in fulfilling these will you lessen the amount of 
exudation and hepatization which are to constitute the second stage of 
the disease. 

When the latter has already supervened, however, then your leading 
objects must be to hasten the disintegration and promote the removal of 
the exudative material, thereby inducing resolution before suppuration or 
caseous degeneration should take place. But if the latter processes do 
make a fair beginning, constituting the third stage, or that usually called 
gray hepatization, your main objects must be to limit the degenerative proc- 
esses and sustain the nutrition and strength of the patient. Such are the 
rational indications for treatment founded on the important pathological 
conditions present in each successive stage of the disease; but the particu- 
lar means most efficient for accomplishing the several objects named, as 
well as the time and manner of their use, will be materially influenced by 
certain coincident conditions relating chiefly to the quality of the blood and 
the general tonicity of the tissues. For instance, if a patient when at- 
tacked with pneumonia has good blood, of natural degree of plasticity, 
and an active vital affinity giving to his tissues a good degree of tonicity, 
his case will present all the characteristic symptoms of an active or 
sthenic grade of inflammation. On the other hand, if the patient when 
attacked had already been exposed to malarial influences until his blood 
was more or less impoverished of its red-corpuscles and nutritive con- 
stituents, with laxity of tissues, or if he had been living in the impure 
air of over-crowded dwellings, or in the midst of other conditions favoring 
typhoid developments, until the plasticity of his blood and the tonicity of 
his tissues were both impaired, his case would present all the character- 
istic features and tendencies of an asthenic inflammation. 

While it is true, therefore, that it is desirable to allay the irritation 
and lessen the vascular fullness in the first stage of all acute inflam- 
mations, whether sthenic, asthenic, or specific, yet the means for accom- 
plishing these results most safely and efficiently, must vary much in the 

* See Meigs and Pepper on Diseases of Children, 4th Ed., pp. 180-1, 1870. 



428 PNEUMONIA. 

several varieties. Morbid susceptibility may be allayed by anodynes, 
anaesthetics, and sedatives; and the vascular fullness or congestion m ly 
be diminished by lessening the quantity of blood in the vessels of t.ie 
part either by venesection, by increasing the contraction of the vessels 
themselves through the influence of the vasomotor nerves, and by lessen- 
ing the action of the heart in forcing the blood into the vascular system. 
A careful examination of the actual clinical results obtained in the 
management of acute inflammatory affections during the last half century 
shows that in the first stage of the active sthenic grade of p.ieumonia one 
prompt and decisive venesection, followed by such cardiac sedatives as 
will lessen the force and frequency of the heart's action, is not only the 
most efficient mode of relieving the vascular fullness, and thereby limit- 
ing the amount of subsequent exudation, but it has been followed by the 
highest ratio of recoveries. In the same stage of those cases occurring 
in patients whose blood is already dim'nished in plasticity, and vessels 
more or less relaxed from malarious influences, from two or three deci- 
grams (gr. iii to v) of sulphate of quinia, given every two to three 
hours, alternately, with some mild cardiac sedative and alterant, will often 
as effectually check the vascular fullness as will the bleeding in the purely 
sthenic cases. In thosi cases, however, occurring in patients who are liv- 
ing in the midst of sanitary conditions strongly predisposing to attacks of 
typhoid or typhus fevers, the adjustment of remedies to meet the indica- 
tions in the first is more difficult. In such patients direct depletion by 
bleedino- is seldom borne without positive injury, and quinia frequently 
fails to produce the effect desired. When called to this class within the 
first twenty-four hours after the initial chill, I have usually ordered six 
powders, each containing sulphate of quinia 0.200 grams (<zr. iii); calo- 
mel 0.066 grams (gr. i); sanguinaria pulverized 0.033 grams (gr. ss); 
and glycyrrhiza pulverized 0.06b' grams (gr. i); one to be given every 
four hours, and four cubic centimeters (fl. 3') of the following mixture 
between: 

r> Liquoris Ammonii Acetatis, 60 c. 
Tincturae Opii Oamphoratae, 60 c. 
Tinctuiae Aconiti Radicis, 4 c. 

At the same time cover the whole affected side of the chest with a lin- 
seed-meal poultice; and if the skin is hot and dry, have all the surface 
not covered by the poultice frequently sponged with milk-warm water. 
As soon as the six powders have been taken, if the bowels have not 
moved spontaneously, they should be induced to move by an enema or a 
mild laxative. That the distinctions I have made in regard to the modi- 
fications or grades of pneumonia, and the variations which they require 
in the choice of remedies for fulfilling the indications presented in the 
first stage of the disease, are neither theoretical nor fanciful, but such as 
actually confront us at the bedside of our patients, I have had abundance 
of evidence in ray own clinical experience. 

From 1837 to 1847, 1 was practicing in a hilly, rugged region, free from 
malaria, and supplied with pure air and good water, in the interior of 
New York, near the northern line of Pennsylvania, where the winters 
were cold, and during which attacks of pneumonia, pleurisy, bronchitis, 
and rheumatism were frequent, and uniformly of the sthenic type. In 
every case, when called during the first stage of the disease, I b ed freely 
once and sometimes twice, and gave internally sedative doses of tartar 



0. 


!« 


C. 


!" 


c. 






TREATMENT. 42 ( J 

emrtic* alternately, with alterative and anodyne doses of calomel and 
Dover's powder. 

The relict to the patient was always well marked, and sometimes so de- 
cisive as to render the amount of exudation in the second stage unimpor- 
tant, and to enable the patients to be up and dressed, with all the indica- 
tions of complete convalescence on the fourth and fifth days. In the 
spring of 1847, I moved to the city of New York, where, during a resi- 
dence of little more than two years, I saw but few cases of pneumonia, 
and those among the poor surrounded by bad sanitary conditions. 

In the autumn of 1840, I came to this city, then without sewers, and 
only a small part of it supplied with lake water. Yet the tide of immi- 
gration was such that every boarding-house was overcrowded, and we had 
an abundance of the idio-miasms added to the malaria naturally prevalent 
in the locality. Here, during the succeeding ten years, I had a rare 
opportunity for studying the modifying effects of malaria and the causes 
favoring typhoid fever on all the acute inflammations, both in their sepa- 
rate action and in all degrees of their commingling. I saw, during the 
latter part of winter and early spring of each year, many cases of pneu- 
monia very promptly relieved by the free use of quinine in the first stage; 
while in other cases more strongly influenced by the causes of typhoid 
diseases, the quinine either produced but little apparent ffect, or else 
added much to the dullness of hearing and stupidity of the mental facul- 
ties generally: and occasionally a case confronted me with all the charac- 
teristics of the sthenic type as strongly as I had seen at an earlier period 
in the interior of New York, and in which a prompt and full venesection 
had the same beneficial effects. In a few of the more severe attacks of 
pneumonia under strongly malarious influences, I have seen much benefit 
from one very early and free bleeding, followed by quinine in effkient 
doses. But I have never seen benefit from blood-letting in cases occur- 
ring in the midst of such sanitary conditions as decidedly favor the devel- 
opment of typhoid or typhus fevers. In the winter of lSoO-'dl, in a 
well-marked case of this variety, I opened a vein in the arm for the 
express purpose of ascertaining experimentally what the effect would be. 
Decided indications of syncope came before I had taken an ordinary tea- 
cupful of blood, and I was obliged to tie up the arm and administer car 
bonate of ammonia and camphor as restoratives. I have calied your 
attention to the treatment of the first or congestive stage of pneumonia 
thus I ully, because it is only in this stage that measures designed for 
directly lessening the vascular fullness and consequently rendering the 
subsequent stages milder and shorter, can be used with benefit to the 
patient. When exudation has already taken place, and the second stnge 
of the disease is fairly developed, further depletive and sedative measures 
are useless and generally injurious. In this stage, the continuance of 
poultices over the chest, and in some cases the addition of a blister, and 
the administration of alterant, anodyne, and expectorant mixtures, and 
mild nourishment, will constitute the treatment best calculated to |>ro 
mote resolution and prevent either purulent or caseous degeneration. 
The following is one of the best alterant, anodyne, and expectorant com- 
binations that I have used: 

$ Ammonii Muriatis, 

Antimonii et Potassi Tartratis, 
Morphiae Sulphatis, 
SyrupusGlycyrrhizae, 

* At that time the more prompt and valuable sedative properties of the veratrum viride, aconite, 
and gelseminum were not known. 



12.CP grams 


3i" 


0.13 " 


gr. ii 


0.20 " 


gr. iii 


130.00 c. c. 


?iv. 



430 PNEUMONIA. 

Four cubic centimeters (fl. 3i) may be given to an adult every three or 
four hours, mixed with a tablespoonful of water. If the urine is scanty, 
a mixture of two parts of liquor ammonii acetatis, two of spirits of ni- 
trous ether, and one part of tincture of digitalis, may be given in doses 
suited to the age of the patient, half way between the doses of the other 
mixture. In most cases fro n two to three decigrams (<_>r. iii to v) of 
sulphate of quinia may be given with benefit, three times a day, until 
convalescence is established. 

In addition to the foregoing outline of the treatment required in the 
different grades and stages of pneumonic inflammation, I must direct your 
attention to some special conditions of importance liable to occur during 
the progress of cases of this disease. One of these conditions is presented 
in some rare cases at the very commencement of the attack, and consists 
of an almost universal congestion or engorgement of the pulmonary vessels 
immediately following the initial chill, indicated by a purplish or leaden 
hue of the surface; short and hurried breathing with very limited expan- 
sion of the chest; small, frequent, and weak pulse; cool extremities, but 
high temperature of the trunk of the body; fine crepitant rales over the 
whole chest, and great sense of oppression or weakness. If such cases 
are seen very soon after the commencement of the attack, it is well to 
open a vein in the arm, and if the blood can be made to flow freely it 
speedily lessens the oppressed breathing, improves the color of the surface, 
and causes the pulse to become fuller and slower. At the same time six 
decigrams (gr. x.) of sulphate of quinia should be given and repeated 
every two hours until three doses have been taken, after which the time 
may be lengthened to four hours. You may gain some further aid in 
restoring the tone of the pulmonary vessels by giving half way between 
the doses of sulphate of quinia two decigrams (gr. iii) of ergotine, and 
after the immediate danger from overwhelming congestion of the pulmo- 
nary vessels has been relieved the subsequent treatment maybe the same 
as in other cases of severe pneumonia. liut if the venesection results in a 
failure to obtain more than a few cubic centimeters (fl. 3 ii ) of dark blood, 
making no impression on the circulation or the respiratory movements, 
the whole chest and trunk of the body should be wrapped in a sheet wet 
in cold water, and the quinine and ergot given internally as just directed. 
Such cases are met with chiefly in highly malarious districts and are always 
dangerous; but if the congestion of the first stage can be relieved in a 
measure, the first crisis will pass by, and the subsequent progress of the 
case be easily controlled. 

Another condition of very much more frequent occurrence may present 
itself to you in the latter part of the second or during any part of the 
third stage of the disease. It is indicated by a quick, weak pulse; short 
and quick systolic action of the heart; a dingy hue of the surface from 
slowness of the circulation in the cutaneous capillaries and impaired vaso- 
motor influence; dullness on percussion and abundant mucous rales over 
the affected parts of the lungs; the sputa thin and mixed with blood, 
or decidedly muco-purulent; the expiratory act short with sudden fall of 
the abdominal muscles; and the mind either dull and drowsy or wander- 
ing. This is the condition described in your books as indicating danger 
from cardiac vieakness, and therefore demanding the liberal use of 
alcoholic remedies, under the impression that alcohol is capable of 
strengthening the systolic action of the heart. Having already given you 
the results of my own clinical and experimental observations concerning 
the incorrectness of this impression, when speaking of the treatment of 
tvphoid fever, I will not repeat what was then said. But as the con- 



TREATMENT. 4ol 

dihon under consideration is the one of chief danger in most cases of 
severe pneumonia, it is of great practical importance to have clear and 
correct ideas concerning its nature. Why is the cardiac force diminished 
and the whole systemic circulation still more enfeebled in these cases? 
Plainly from two causes. First, the volume of blood in the vascular 
system has been largely depleted by the exudation and lodgment of from 
one to two liters (fi. §xxx to fix) of it, in the inflamed and hepatized 
portion of the lungs. Second, the filling up of so large a part of lung 
structure has so far diminished the oxygenation and decarbonization of 
the blood that it fails to sustain the sensibility and action of the whole 
vasomotor and cardiac nervous systems. The negative effect of a de- 
ficient amount of oxygen and the positive sedative and anaesthetic effect 
of an excess of carbonic acid gas in the blood, are obviously the chief 
agents in diminishing the force of circulation through their anaesthetic 
and sedative effect on the nervous structures just mentioned. Your 
remedial measures, then, should be such as will directly increase the 
activity of the vasomotor nerves, and improve the oxygenation and 
decarbonization of the blood, and thereby increase the action of the 
muscular coat of the small vessels and sustain the molecular movements 
in the secreting organs and tissues generally. To merely increase the 
muscular force of the heart, if this were possible, without simultaneously 
increasing the action of the smaller vessels and quickening molecular 
movements in the tissues, would only result in a temporary show of im- 
provement to be speedily followed by more accumulation in the already 
obstructed and enfeebled pulmonary capillaries. The measures which I 
have found best calculated to relieve the condition under consideration, 
are a fair sized blister over the affected side of the chest, and the use of 
the following remedies internally. I dissolve ten grams (3ii ss) of chlorate 
of potassium and fiiteen grains (3 iv) pulverized gum arabic in 260 cubic 
centimeters (f viii) of water, and give fifteen cubic centimeters or an ordi- 
nary tablespoonful every three hours, in conjunction with from thirteen to 
twenty centigrams (gr. ii to iii) of sulphate of quinia; and half way be- 
tween these doses four cubic centimeters (fl. 3i) of the following formula: 

IJ, Liquoris Ammonii Acetatis, 
Tincturae Opii Camphoratse 
Tincturae Digitalis, 
Ammonii Carbonatis, 

Mix. Dilute each dose with two tablespoonfuls of sweetened water 
when given. At the same time I require from thirty to sixty cubic cen- 
timeters (fl. fi to |ii) of milk and fiiteen cubic centimeters (fl. |ss) of & 
strong infusion of coffee, to be given every two hours. To this sugar may 
be added or not as the patient prefers. If when night comes the cough 
is frequent and the patient restless, I give a single dose of the formula 
containing muriate of ammcnium, which I gave you in the earlier part of 
the present lecture. During the last thirty-five years I have been called 
to many cases of acute pneumonia in which the patients had continued to 
fail notwithstanding the liberal use of alcoholic remedies and nourish- 
ment, and have entirely omitted the former, substituting therefor the 
treatment I have just detailed with the most satisfactory results. The 
chlorate of potassium indirectly, and the digitalis, coffee and quinine di- 
rectly, constitute our most reliable cardiac and vasomotor tonics in these 
cases. 

When giving you the clinical history of pneumonia, T stated that cases 



60.0 c. c. 


Iii 


30.0 " " 


?i 


30.0 " " 


|i 


8.0 grams 


3ii 



432 CHRONIC PNEUMONIA. 

had been occasionally met with in which the inflammation terminated in 
the formation of one or mure circumscribed abscesses in the parenchyma 
of the lung. Such cases are very liable to terminate fatally from exhaust- 
ion. But in some instances the abscess has formed an opening into one 
or more of the bronchi, and the pus has been discharged by co gh rig in 
large quantities, often streaked with blood and emitting a mo. e or less 
offensive odor. If the abscess is not large and the bronchial opening is 
sufficient to afford free exit to the matter, the patient may steadily im- 
prove until full recovery takes place, leaving only a cicatrix in the place 
of the abscess. But if the bronchial opening communicating with the 
abscess is small, the purulent discharge will take place at irregular inter- 
vals, only partially draining the suppurative cavity, and exciting more or 
less irritation in the lining of the bronchi through which the matter passes 
on its way out, until the hectic fever and copious night sweats result in 
entire suspension of nutrition and death of the patient. A few months 
since, a case of this kind came into the Mercy Hospital, giving the clin- 
ical history of an acute attack of inflammation of the lower and middle 
parts of the left lung, and affording all the rational and physical signs of 
an abscess in the parenchyma of the left lung, having its center a little 
below and to the left of the nipple. The patient had begun to discharge 
by coughing at irregular intervals about twice in twenty-four hours large 
quantises of pus emitting a very offensive odor. The patient continuing 
rapidly to fail in flesh and strength, what was supposed to be the center 
of the abscess was punctured with an aspirator needle by my colleague, 
Prof. E. Andrews, in one of his surgical clinics. Finding pus, a free 
incision was made giving exit to a considerable quantity of very thick 
and offensive pus. An improved drainage tube was inserted and the 
cavity daily washed out with mild antiseptic solutions. From this time 
his cough and expectoration diminished rapidly until both ceased, and in 
a few weeks he had ^o far regained his flesh and strength as to enable 
him to attend to his ordinary business, though still under the supervision 
of the professor of clinical surgery. 

Gangrene of some portion of the lung as the result of acute pneumo- 
nitis, is still more rare than circumscribed abscesses, and more certainly 
fatal in its results. The treatment must consist of anodynes to promote 
rest, antiseptic inhalations to lessen the offensiveness of the breath, and 
such tonics as tend to sustain the nutritive processes, with as much plain, 
easily digestible food as the stomach will bear. 

CHRONIC PNEUMONIA. 

A chronic form of disease of evident inflammatory character is occasion- 
ally met with in the connective tissue and parenchyma of the lungs. In 
one class of cases it has followed as the sequel of a more acute attack of 
either pneumonia or of broncho-pneumonia, while in another class it has 
supervened without any preceding acute or subacute symptoms. The 
cases belonging to the latter class have been described by some writers as 
true pulmonary cirrhosis resulting from the same form of morbid action 
in the connective tissue as that which attends cirrhosis of the liver. 

Clinical History. — The cases you will meet following acute pneumonic 
attacks differ much in their symptoms, progress and results. They are 
capable, however, of being arranged in two groups. Those constituting 
the first group are met with as the sequelae of acute pneumonia in patients 
already affected by some constitutional predisposition or diathesis, such as 
the scrofulous, tuberculous or syphilitic. In many such cases the primary 



SYMPTOMS. 433 

pneumonic attack runs its course, and the patient presents the appear- 
ance of convalescence. That is, his fever subsides, secretions become 
natural, appetite returns, and he begins to move about and thinks he will 
soon be as well as usual. Still, when carefully noticed, he looks unusually 
pale in the morning and becomes weary from very little exertion; his 
pulse is found from ten to fifteen beats faster than natural, especially in 
the afternoon and evening; his respirations accelerated in about the same 
proportion, with unnatural shortness of breath when walking or ascending 
stairs; and a failure to regain the usual amount of flesh. After remaining 
in this condition for a period varying from two or three weeks to as many 
months, he begins again to cough some, especially in the mornings; to 
feel occasional pains in his chest; to look more flushed and feverish in the 
evening, and frequently to sweat in the last half of the night. He thinks 
he has taken "some cold," and recalls his physician, who now finds him 
with all the symptoms of incipient hectic fever. His pulse is quick and 
irritable, varying from 100 to 120 per minute; respirations short and fre- 
quent, especially when attempting a little exercise; cough frequent but 
most severe in the latter part of the night and early morning, accom- 
panied by an expectoration of more or less yellowish muco- purulent mat- 
ter; temperature varies from 38 s C. (101° F.) in the morning, to 40° C. 
(104 c F.) in the evening, with some sweating on the approach of morning; 
his urine is redder than natural and less in quantity, and his appetite 
poor. A phvsical examination shows decided increased fremitus of voice 
and dullness on percussion over the side in which the pneumonia was 
primarily located, with tubular respiration and some degree of sharp sub- 
mucous rales in one or more places which are not temporarily removed 
altogether by an act of coughing. Such patients now emaciate rapidly; 
the expectoration becomes more copious and purulent, often containing 
little masses of caseous matter and sometimes shreds of connective tissue; 
the night sweats become more profuse; the appetite fails; apthse appear 
in the fauces; the intestinal discharges become thin and are repeated 
from two to four or six limes in the twenty-four hours, and the patient 
generally reaches a fatal degree of exhaustion in from three to six months 
after the primary attack. These are the kind of cases which were desig- 
nated by the older writers as quick or "galloping" consumption. An ex- 
planation of the symptoms and progress I have detailed is to be found in 
the fact that the exudative material which accumulated in the inflamed pul- 
monary structure during the primary attack, was of such quality that 
instead of undergoing resolution as convalescence approached, it under- 
went caseous degeneration, and subsequently purulent change; the com- 
mencement of the latter giving rise to renewal of active symptoms and 
the subsequent extensive suppurative changes in the lung structure. 

A similar exudation sometimes accompanies a low grade of pneumonic 
inflammation following a primary pulmonary hemorrhage in persons pre- 
disposed to phthisis, and subsequently undergoes the same successive 
changes, constituting an acute caseous form of consumption as described 
by Niemeyer and others. 

The cases of chronic pneumonia following acute attacks constituting 
the second group to which I have alluded, occur in a very diiferent class 
of patients from those I have just been describing, namely, those whose 
blood and tissue properties favor exudations of a highly pkstic character, 
and consequently tending to permanent organization. 

Cases of broncho-and pleuro-pneumonia occurring in previ usly vigor- 
ous and healthy subjects, and still more in those of a rheumatic diathesis, 

28 



434 CHRONIC PNEUMONIA. 

are the ones m st liable to have some part of the pneumonic exudation 
undergo perman- nt organization, and consequently continue to fill the 
alveoli and interstitial spaces after the acute stage of the disease has 
passed and convalescence is apparently established. 

The majority of such patients so far recover as to resume t'>eir usual 
habits and business of life, and for a long time complain only of shortness 
of breath when exercising or making any extra exertion; of undue sen- 
sitiveness to atmospheric changes; of frequent derangements of digestion 
chiefly from deficient secretion of the gastric juice; and of occasional 
wandering pains in the chest. But percussion shows less than the natu- 
ral degree of resonance, and auscultation detects increased fremitus of 
voic • over the affected part of the Jungs, with less than the natural res- 
piratory murmur. 

If, after six or twelve months have passed the patient comes under ex- 
amination, the same general condi ion of health and the same physical 
signs w T ill be found, together with a contraction of the affected side of the 
chest, a marked difference in the expansion of the two sides during or li- 
nary inspirations, and a more constant feeling of weariness and dull pain 
or oppression in the chest. The latter is apt to be increased by exercise 
of the arms or in the performance of manual labor; and at such times 
slight feverishness and a dry hacking cough are sometimes present. Some 
persons remain in this condition of impaired health, yet attending more 
or less to the ordinary duties of life for many years. But the long-con- 
tinued deficiency in the performance of the respiratory function, render- 
ing the oxygenation and decarbonization of the blood defective, in most 
■cases ultimately induces fatty, atheromatous, or caseous degenerations 
either in the affected part of the lung developing all the phenomena of 
pulmonary phthisis, or in the liver, kidneys, or heart, giving rise to some 
form of dropsical accumulations, or to progressively increasing cardiac 
weakness and irregularity ending in vertigo and sometimes paralysis, or 
sudden death. The remaining class of cases, described bv Corrigin and 
Bastian as constituting true pulmonary cirrhosis, but regarded by Charcot, 
Wilson Fox, and others as identical with chronic pneumonia, are not of 
frequent occurrence. You will find the same class of cases described by 
Drs. Flint, Bartholow, and Palmer, in their respective works, under the 
name of fibroid phthisis. Some other writers have called them cases of 
interstitial pneumonia or sclerosis of the pulmonary structure. But what- 
ever may be the name adopted, a careful examination of the clinical his- 
tories, so far as they are given, show that nearly all the cases are traceable 
to primary chronic capillary bronchitis, becoming complicated in some 
stage of its progress with lobular pneumonia, as I described when speak- 
ing to you of that form of bronchitis a few days since. 

The inflammatory action thus extending into the pulmonary lobules 
causes increased irritability and growth of the connective tissue and cell 
walls which, added to the obstructed bronchioles, diminishes the capacity 
for air, and constitutes a pathological condition perhaps more analogous 
to sclerosis of the central parts of the nervous structures, than to 
cir hosis. Yet the exclusion of air which it involves pretty uniformly 
leads to marked contraction of the affected lung. Writers generally 
claim that this form of disease is met with almost exclusively in adult 
life, and generally between the ages of thirty and fifty years. Yet some 
of the most characteristic cases that have come under my own observa- 
tion have been in children between five and ten years of age. My own 
clinical and post mortem observations have led me to the conclusion that 
the usual order of anatomical changes in the cases under consideration, 



SYMPTOMS. 435 

is, fust, a true sclerosis from chronic inflammation of the connective tissue 
constituting the alveolar and lobular septa and vascular walls, forming 
dense bands and irregular nodules often stained with dark pigment; sec- 
ond, exudations from the congested and obstructed vessels filling the 
alveoli and interstitial spaces with fibrous material containing lymphoid, 
spindle-shaped and giant cells much resembling small tuberculous granu- 
lations; and third, the same exudative material accumulated in larger 
masses and presenting various stages of degeneration either calcareous, 
cheesy, or semi-purulent. It has seemed to me that all these are only 
different stages of the same morbid processes, often observable at differ- 
ent points in the same section of diseased lung; and differing from pri- 
mary tuberculosis, in having originated from direct inflammation or 
hyperplasia of the pulmonary structure and often preceded by capillary 
btonchitis, pleurisy, or more active pneumonitis. After the disease has 
progressed for several months, the imperfect and unequal expansion of 
the chest from the obstruction or obliteration of the alveoli and the ex- 
c usion of air, favors dilation of many of the smaller bronchi, and general 
contraction of the diseased lung, with corresponding contraction of that 
side of the chest. 

Symptoms. — The chief symptoms are a frequent and harassing cough, 
accompanied usually in all the earlier stages of the disease by only a 
scanty mucous expectoration, later becoming muco-purulent, and some- 
times offensive to the smell; shortness of breath, always increased by ex- 
ercise; but with less disturbance of the pulse and less emaciation than the 
other symptoms would lead us to expect. Inspection of the chest shows 
marked contraction of the affected side laterally, similar to that which 
often follows attacks of acute pleurisy, and not the flattening or reced- 
ing of the infra-clavicular reg'ion, which is generally seen in ordinary tu- 
berculosis. Percussion reveals increased dullness over the affected side, 
with here and there tympanitic, amphoric, or cracked metal sounds, owing to 
different degrees of dilatation of the bronchi, the last named sound existing 
only when some dilatation has become sacculated and partly filled with 
rauco-pus. Auscultation may reveal only feeble or suppressed respiratory 
murmur with increased fremitus of voice and some moist bubbling rales; or 
there may be tubular or cavernous, or broncho- vesicular sounds according 
to the degree of the bronchial dilatations. When the disease has existed 
for several years, as is the case with many patients, the long continued 
contraction of the affected lung, retarding the flow of blood through it, 
causes the right cavities of the heart to become dilated and the tricuspid 
valve insufficient, allowing regurgitation or double cardiac murmur and 
jugular pulse, and sometimes general dropsy. Although the disease is 
generally very slow in its progress, in some instances continuing from 
five to twenty years, yet sooner or later the structural changes reach that 
degree of purulent degeneration which affords abundant expectoration, 
and ends in extensive emaciation, hectic fever and fatal exhaustion. 

Pulmonary hemorrhages occur during the progress of many of this 
class of cases, but not in all. 

Prognosis. — The cases belonging to the class of chronic pneumonia 
now under consideration, are seldom recognized by accurate examinations 
until the anatomical changes in the lung tissue, just described, have be- 
come well established, and then they are incapable of removal. Conse- 
quently the prognosis is very unfavorable, although the progress of the 
disease may be retarded, and sometimes kept stationary, for a long period, 
by judicious treatment, and still more by a residence in a mild and dry 
climate. 



436 CHRONIC PNEUMONIA. 

Treatment. — As I have just remarked, in reference to the prognosis in 
the last variety of cases described, so I may say in reference to all the 
varieties of chronic pneumonia, when they have progressed so far as to 
develop well established structural changes, they are not curable in the 
sense of complete restoration to health. Yet much may be done through- 
out all stages of their progress to palliate the more distressing symptoms 
and to prolong the lives of the patients. And in some cases when the di- 
agnosis is made early and the treatment adopted judicious and faithfully 
pursued, permanent recoveries have taken place. To give each patient 
the full benefit which his case is capable of receiving from appropriate 
treatment, you must have an accurate knowledge of the actual patholog- 
ical conditions existing in each case, which can be gained only by a care- 
ful tracing of its history, its present general symptoms, and a thorough ap- 
plication of the methods of physical examination and diagnosis. While 
attending cases of acute pneumonitis, whether of the lobar or lobular vari- 
ety, in which hepatization has characterized the second stage, you should 
regard it as a necessary rule of practice to note carefully the progress of 
resolution during the decline of the disease. And when convalescence 
appears to have been fairly established it is proper to give the affected 
side of the chest a careful examination by auscultation and percussion. 
If the continuance of well marked dullness on percussion and imperfect 
inflation of the lung in ordinary inspiration, shows that the resolution or 
clearing up of the lung structure is tardy or incomplete, it should receive 
careful attention. If the patient is known to possess a scrofulous or tu- 
berculous tendency, either hereditary or acquired, special care should be 
taken to promote healthy nutrition hj a sufficient variety of easily digest- 
ible food, aided by such remedies as the syrup of lacto-phosphate of cal- 
cium, syrup of iodide of calcium, compound syrup of the hypophosphites, 
and cod-liver oil when it is well received by stomach, and as good a sup- 
ply of pure air as possible. Exercise is also important, and should consist 
at first in gentle or cautious efforts to innate the lungs two or three times 
a day, but may be gradually extended until it embraces riding, driving, 
and moderate walking, ending when necessary and practicable in a change 
to a milder and dryer climate at moderate elevations. By such a course, 
promptlv adopted and judiciously executed, you may arrest the further 
caseous degeneration of the exudate in the lung and induce its ulti- 
mate calcification or disappearance by slow disintegration and removal. 
But if in spite of your best directed efforts the deteriorative changes pro- 
gress until caseous and purulent products are completed, with rapid emaci- 
ation and hectic fever, you can do but little more than palliate the more 
troublesome symptoms by measures which will be more fully explained 
when I come to speak of the management of the advanced stage of tuber- 
cular phthisis. 

When the exudate in the acute stage of pneumonitis has been un- 
usually plastic, leaving after convalescence the alveoli and interstitial spaces 
filled by permanently organized false tissues as I have previously described, 
advantage may be gained by a somewhat protracted use of either the 
iodide of potassium or muriate of ammonium in moderate doses three 
times a day, and the daily practice of cautious but full inspirations and 
such training of the chest and arms as is calculated to re-establish as good 
% capacity for air as possible. In those cases following attacks of capillary 
bronchitis complicated with lobular pneumonia, which I have described as 
including both the fibroid or catarrhal phthisis and the pulmonary 
cirrhosis of different writers, I have found no combination of remedies 
more efficient in allaying the cough, lessening the soreness and feeling of 



PLEURITIS. 437 

constriction in the chest, and promoting the removal of the exudative 
material without suppuration, than the formulae containing muriate of am- 
nion' urn, already stated to you during the present lecture.* To adults it 
may be given in doses of four cubic centimeters (fl. 3i) from two to four times 
a dav, according to the severity of the symptoms. The functions of the 
digestive organs, including regular evacuations, should be sustained by 
the use of mildly laxative and tonic remedies, and by such judicious 
exercise daily in the open air as the patient is able to endure without 
fatigue. Many of the cases belonging to this class are much benefitted 
by the inhalation of resinous and anodyne vapors. Perhaps the best of 
these is the combination of carbolic acid, oil of scotch pine, and camphor- 
ated tincture of opium, which I mentioned when speaking of the treat- 
ment of certain conditions in the progress of chronic capillary brotichitis.f 
But the most important of all remedies for this class of patients, is an early 
and judicious choice of a residence in a mild and genial climate. The 
southern part of California, the district of Texas represented by San 
Antonio, some places in New Mexico, and many in Mexico, afford resi- 
dences of the greatest value to a large proportion of these cases, if made 
available before the structural changes have advanced too far. It is the 
mild, dry, and pure air at moderate elevations (from 1,500 to 3,000 feet) in 
these districts of country that is most beneficial. For a temporary resi- 
dence during the winter months, the orange grove regions of the interior 
of Florida, and many other places in the interior and moderately elevated 
districts of Georgia, Alabama, and South Carolina, afford good advantages. 
For such as need the influence of sea-air in connection with mildness of 
climate, the Bermuda and Sandwich Islands are well adapted; and the 
Bermudas especially are easy of access lor the citizens of this country. 



LECTUKE XLV. 



Pleuritis-- Acute and Chrome: Thair Clinical History, Anatomical changes, Diagnosis, Prognosis 
and ireatment. 

GENTLEMEN: The remaining important structure constituting a part 
of the respiratory organs, the inflammations of which I have now to 
co sider, is the serous membrane called the pleura, which forms both an 
external covering of the lungs and an internal lining of the parieties of 
the chest. Consequently the membrane on each side constitutes a closed 
or complete sac, the smooth, free surface of which is covered with a single 
layer of endothelial cells and is everywhere in contact with itself. In 
the natural condition the surface is constantly moistened by a small quan- 
tity cf serous fluid. In addition to the layer of endothelial cells on the 
s\irface, the membrane is composed of white connective and elastic fibers; 
a net work of capillaries derived from the larger vessels in the sub- 
serous layer of tissue, and lymphatics. The pleural membrane may be 
attacked with inflammation at any period of life, and at any season of 

* See page 429. 
t See page 409. 



438 PLEURITIS. 

the year; although much the larger number of cases occur in the colder 
months of the year, and in such climates as are characterized by sudden 
and extreme changes in the thermometric and hygrometric conditions of 
the atmosphere. Males appear to be more liable to the disease than 
females. The great majority of attacks are unilateral, but in some rare 
instances the inflammation invades both membranes at the same time and 
is called double pleuritis. On the other hand it may be limited to only a 
small part of one pleura, constituting circumscribed pleuritis. 

The grade of the inflammation may be acute and rapid in its progress, 
or chronic and persistent in duration. 

Symptoms of Acute Pleuritis. — An attack of acute pleurisy is gener- 
ally abrupt in its beginning and characterized by well marked symptoms. 
In some cases, however, slight pains and feelings of depression are noticed 
for two or three days prior to the commencement of the more severe 
symptoms. 

Most of the acute cases are ushered in by a chill or brief period of 
rigors, accompanied by paleness and coolness of the surface, small pulse, 
short and unsteady respiratory movements, and sharp piercing pains in 
one side of the chest, more frequently in the sub-axillary region than else- 
where. The coldness soon gives place to heat and dryness of the sur- 
face; some flush of redness in the face; a full firm pulse accelerated in 
frequency to 90 or 100 per minute; respirations short and frequent being 
voluntarily stifled as much as possible to prevent the increase of pain in 
the side; a short, dry cough which, like the respiratory movements is sup- 
pressed as much as possible to prevent increase of pain. 

The secretions generally are diminished, as in other acute inflammations, 
and the tongue in most cases covered with a thin white fur. If the 
affected side of the chest is examined within eighteen or twenty-four 
hours after the initial symptoms by auscultation and percussion, the only 
unnatural sign discoverable will be a rubbing or friction sound synchro- 
nous with the respiratory movements. If the examination is made at any 
later period during the progress of the disease, in most cases the friction 
sound will have ceased, and in its stead you will find marked dullness on 
percussion, increased vibration of voice, in some cases amounting to 
cegophony, and absence of respiratory murmur. These signs indicate the 
commencement of the second or exudative stage of the inflammatory 
process with sufficient effusion of serous fluid to separate the surfaces of 
the pleura by compressing the lung, and to some extent, increasing the 
size of the affected side of the chest. In all the more acute cases, the 
symptoms of general irritative fever, sharp local pains, and stifled respira- 
tions, continue without abatement from three to five days, or until the 
accumulation of inflammatory products in the cavity of the pleura and 
its consequent distension with serous or sero-purulent fluid, has become 
sufficient to render the oxygenation and decarbonization of the blood de- 
fective. Then, the temperature begins to diminish; the pains to be less 
acute and less frequent; but the shortness of breath and sense of oppres- 
sion in the chest have increased, the pulse has become smaller and more 
frequent, and the patient complains much of weariness, yet is wholly 
unable to rest in any other than the sitting or semi-erect position. 

In some of the most severe cases, by the end of the first week the sac 
of the inflamed pleura has become fully distended rendering the 
whole affected side of the chest completely dull on percussion, consider- 
ably enlarged with the intercostal spaces bulging or convex, and the lung 
compressed into the upper and back part of the chest, thereby suppressing 



SYMPTOMS. 439 

all respiratory sounds and restricting the motions of the chest in inspira- 
tion and expiration to the well side. If the left pleura is the seat of the 
disease its distension to the extent just described will push the heart from 
its natural position further to the right until its impulse and natural 
sounds arc both felt and heard to the right of the sternum. As a general 
rule the cris.s of the disease is reached by the end of the first or during 
the first half of the second week of its progress, after which the febrile 
symptoms and local pains soon cease. But the shortness of breath and all 
other symptoms and physical signs caused by the mechanical distension of 
the pleural sac will abate more slowly, and may keep the patient confined 
several weeks before the accumulated inflammato^ products will have 
been entirely removed and the respiratory function freed from embarrass- 
ment. In the milder cases, however, the first or stage of vascular en- 
gorgement will occupy from one to two days; the second or stage of ex- 
udation and effusion from three to five days; and the third or stage of 
resolution and re-absorption of inflammatory products only from seven to 
nine days more, making the average duration of such cases from eleven to 
sixteen days. 

The symptoms and clinical history I have thus far given you apply with 
sufficient accuracy to the great majority of cases of acute pleuritis as they 
are met with in general practice. But there are several deviations from the 
usual course of the disease, of sufficient importance to require attention. 
In a few instances, even of unilateral pleuritis, the serous effusion into the 
pleural sac accumulates so rapidly during the second stage of the inflam- 
matory process as to completely compress the one lung and crowd the me- 
diastinum so far to the opposite side as to materially lessen the expansion 
of the other. In such cases the patient feels a most distressing sense of 
suffocation and exhaustion from want of air; his extremities become cold, 
and the whole cutaneous surface passively congested or cyanozed; the 
pulse is small, frequent and feeble, and unless speedily relieved by surgi- 
cal interference, the patient dies from apncea or insufficient supply of air 
to the pulmonary alveoli. 

A case of this kind was received into the medical department of the 
Mercy Hospital a few years since, in which the symptoms of suffoca- 
tion were so urgent that I deemed it necessary to diminish the amount of 
effused fluid by tapping the affected side of the chest, at once, with an 
ordinary trochar. Four liters (between 8 and 9 pints) of serum were 
drawn off, much to the relief of the patient, who subsequently recovered. 
The danger of death from compression of the lungs during the second 
stage of the disease is much greater when the inflammation has attacked 
the pleural membrane in both sides of the chest at the same time. An- 
other deviation from the ordinary course of the disease is manifested by 
the occurrence of one or more chills during the second stage followed by 
higher fever, more rapid pulse, shorter breathing, and greater restlessness, 
ending in from six to twenty-four hours by a copious sweat. The fever 
now assumes a distinct hectic type, with rapid loss of flesh and strength, 
while the signs of fluid accumulating in the pleural sac daily increase, 
until the symptoms of exhaustion and approaching apncea indicate ex- 
treme danger to life. The occurrence of the chills and more decided 
hectic symptoms usually indicate the commencement of the suppurative 
process in the inflamed membrane, and the consequent intermixture of 
pus with the serous effusion. In some cases the accumulated fluid con- 
sists wholly of pus, constituting empyema, as distinguished from serous 
and aqueous accumulations called hydrothorax. In some of the pleuritic 
inflammations occurring in tuberculous subjects, the inflammatory affection 



440 PLEURITIS. 

is circumscribed or limited to a small portion of the membrane, is slower 
in its progress, accompanied by less active general febrile phenomena, and 
yet the resulting accumulation of sero-purulent fluid may be as copious 
and as oppressive to the respiratory function as in cases involving a larger 
part of the membrane. 

It sometimes happens in cases of suppurative pleuritis, especially when 
connected with the suppurative stage of pulmonary tuberculosis, that gases 
as well as pus are formed in the pleural cavity adding to the distension 
of the side and embarrassment of respiration, and yet giving you increased 
or tympanitic resonance instead of dullness over a large part of the 
affected side. The same effect is capable of resulting from the perfora- 
tion of the pleura by the extension of superficial tubercular abscesses or 
cavities in the lung, and the escape of air as well as matter into the 
pleural sac. One more deviation which you may occasionally meet with, 
results from the unusually plastic quality of the exudative material that 
accumulates upon the surface of the inflamed membrane during the 
earlier stages of the disease. In some rare cases the exudate will be 
wholly plastic, and by undergoing rapid organization into a layer of false 
membrane, will result in the firm adhesion of the pulmonary to the costal 
pleura. In such cases the symptoms of the first stage undergo less 
change during the second; the layer of plastic exudate not occupying 
sufficient space to either compress the lung or perceptibly enlarge the 
affected side of the chest, the respiratory murmur and even some friction 
may continue through the whole of the second stage, and the dullness 
from percussion usually so strongly marked in cases attended by serous 
effusion, does not supervene. The adhesions formed during the active 
stage of these cases, remain after convalescence and generally through 
life. During the first few months they are apt to cause some feeling of 
constriction or embarrassment when the patient takes full inspiration or 
exercises actively. And the same causes often occasion slight pains or 
temporary feelings of soreness in the affected side of the chest. But in 
nearly all the cases the layer of new or adventitious tissue which consti- 
tutes the bond of union between the two surfaces of the pleura, under the 
constant influence of the respiratory movements, becomes gradually more 
smooth, attenuated in structure, and its fibers elongated, until it ceases to 
produce any perceptible embarrassment or inconvenience to the patient. 
More serious results, h wever, attend and follow attacks of acute pleu- 
ritis in many young and vigorous subjects. They are cases in which the 
second stage of the inflammatory process gives rise to both copious serous 
effusion and abundant plastic exudate. The former rapidly distends the 
pleural sac and compresses the lung, producing all the symptoms and 
physical signs I have already mentioned when giving the history of ordi- 
nary cases of the disease; while the latter, continuing to accumulate on 
the surface of the pleura covering the compressed lung, becomes so firmly 
organized during the protracted period, sometimes intervening before the 
effused fluid is re-absorbed or otherwise removed, that it effectually re- 
sists the renewal of expansion of the lung in proportion to the removal 
of the serous fluid. This not only subjects the patient to a continuance 
of shortness of breath and all the consequences of diminished capacity 
for air after the establishment of convalescence, but the ribs and walls of 
the affected side of the chest yielding to atmospheric pressure become 
depressed or sunken laterally in proportion to the deficiency of expan- 
sion of the lung. In some cases this permanent lateral contraction of the 
chest is sufficient to cause a lateral curve in the spine and tilting; of the 
shoulders, constituting a marked deformity of the chest. 



CHRONIC PLEURITIS. 441 

Having given yon, thus in detail, the symptoms which characterize the 
several stages of acute pleuritis and the pathological changes accom- 
panying them under the varying circumstances in which the disease may 
occur, but few words need be added concerning the symptoms and prog- 
ress of the disease in its chronic form. 

Chronic Pleuritis. — This grade of the disease may follow as the sequel 
of an acute attack, but is much more frequently chronic or subacute from 
its beginning. Cases have been met with at all periods of life, though very 
much the larger number occur between the ages of fifteen and forty 
years. Patients suffering from pulmonary tuberculosis and from albu- 
minuria dependent on either acute or chronic renal disease, are more 
liable to attacks of chronic inflammation of the pleura, yet the larger 
number cf cases of the last named disease occur in persons previously 
in fair health, and without any recognized cause. I have seen a consider- 
able number of cases that were traceable to the effects of mechanical 
violence from blows, falls, or severe strain upon the chest; and some 
others that were clearly the result of sudden exposure to wet and cold. 

Symptoms. — In the chronic form of pleurisy, the subjective symptoms 
in the early stage are generally slight; so much so that in many cases the 
patients neither cease attending to their ordinary business nor think it 
necessary to consult a physician, until the second stage is far advanced 
and the amount of the serous effusion is sufficient to compress the lung 
and render the respirations uncomfortably short. Yet on close exami- 
nation nearly all the patients acknowledge that they have had more or less 
pains, or sense of soreness in the affected side of the chest, increased by 
active exercise or full inspirations, from the commencement of the disease. 
And in addition most of them complain of having had slight chills al- 
ternately with flushes of heat, dryness of the mouth, variable appetite, 
scanty and high colored urine, and imperfect digestion of food. After 
these mild and apparently unimportant symptoms have continued from 
two to four weeks, there are added shortness of breath, especially when 
taking active exercise or when. lying in a horizontal position on the well 
side; a short dry cough; moderate acceleration of pulse; and general sense 
of weariness. The objective symptoms, or those developed by direct 
physical examination of the patient, are more characteristic and therefore 
important in making a correct diagnosis. In nearly all the cases the 
clinical thermometer will show a temperature at least one or two degrees 
above the natural standard; and during the early stage auscultation will 
reveal some degree of rubbing or friction sound, increased by full inspi- 
rations, but often limited to a small space on one side of the chest. At this 
stage no changes are usually detected by percussion and measurement. 
At a later stage, however, when the patient begins to be embarrassed from 
shortness of breath, auscultation will reveal neither friction nor respiratory 
murmur over the affected side, but in their place sometimes tubular 
sounds and some increased fremitus or vibration of voice; while percus- 
sion will elicit decided dullness over the most dependent part of the 
chest in whatever position the patient may be placed, accompanied by in- 
creased fullness or bulging of the intercostal spaces and diminished 
respiratory movements. These signs taken together with the subjective 
Fymptoms indicate very certainly an accumulation of fluid in the cavity or 
sac of the pleural membrane sufficient to compress the lung; and the sub- 
sequent progress of different cases may develop all the varied conse- 
quences and changes that 1 have already described as liable to follow ac- 
cumulations of serum, pus, or gases resulting from attacks of acute 
pleuritis. When the effusion resulting from chronic pleuritis is serous, 



442 CHRONIC PLEURITIS. 

constituting one of the forms of hydrothorax, the slower progress of the 
accumulation causes less embarrassment to the respiration than when it 
takes place more rapidly in the acute form, and consequently is sometimes 
allowed to continue until the quantity of fluid and degree of distension 
of the pleural sac is greater than in any other class of cases. In cases in- 
volving suppurative action in the inflamed membrane, causing the elf used 
fluid to be pus, constituting pyothorax or empyema; or a mixture of serum 
and pus, constituting hydro- pyothorax; the more rapid loss of flesh and 
strength, and the more decided febrile movements accompanying such 
c.ises, usually lead either to earlier surgical interference for the removal 
of the pleural accumulation or the death of the patient, before the quantity 
accumulated has become so great as in the cases of serous effusion. 
Gases or air may accumulate in the pleural sac during the progress of 
chronic pleuritis under the same circumstances as I mentioned in 
relation to the acute form of the disease. 

Pathological Anatomy. — The structural changes which accompany the 
several stages of acute and chronic pleuritis are the same in kind as take 
place in all inflamed structures. At first the blood rapidly accumulating 
in the capillaries and smaller vessels gives the membrane an intensely red 
and tumefied appearance. A few hours later you may find the white or 
migrating corpuscles and liquor sanguinis passing from the overdistended 
capillaries into the interstitial spaces of the membrane and upon the free 
surface where its fibrinous element rapidly solidifies into patches or a layer 
of white pseudo-membrane adherent to the endothelial layer of cells upon 
the surface, while the watery element of the effused fluid accumulates in 
the pleural sac, holding in solution more or less albumen and enough leu- 
cocytes and detached endothelium to give it a slightly turbid appearance. 
In many cases you may also find red corpuscles entangled in the meshes 
of the fibrinous exudate, both in the structure of the membrane and on its 
free surface. 

If the inflammatory process should be protracted or degenerate into the 
chronic form you will have added to the inflammatory products ahead}*- 
mentioned, lymphoid cells and hyperplasia of the connective tissue, caus- 
ing the membrane to appear thicker and harder than natural. During the 
third or declining stage of the disease, all these inflammatory products 
may undergo disintegration and removal by absorption, constituting reso- 
lution and recovery; or the cell elements may degenerate into pus cor- 
puscles, much of the fibrin into fat granules, and these with the serous 
effusion continue to accumulate until, partly by mechanical compression 
of the lungs and in part from exhaustion, the case reaches a fatal termi- 
nation, as I have already described. 

Prognosis. — A very large majority of the cases of uncomplicated pleu- 
ritis, confined to one side of the chest, terminate favorably. When the 
inflammation attacks the membrane in each side of the chest at the same 
time, and is accompanied by much serous effusion, there is great danger 
of a fatal result from apncea. Cases that become complicated with pneu- 
monia, pericarditis, or acute nephritis are more dangerous than when un- 
complicated, and still more so are those that occur during the progress of 
chronic renal diseases, pulmonary tuberculosis, or constitutional syphilis. 
The pleuritic inflammation, whether acute or chronic, when occurring in 
connection with the last named constitutional conditions, is very liable to 
take the suppurative form and lead to purulent or sero-purulent accumu- 
lation and a persistent wasting of flesh and strength until death results 
from asthenia. Early evacuation of the purulent accumulations, efficient 
drainage, and the judicious use of antiseptics, tonics, good food and pure 



DIAGNOSIS. 443 

air will relievo many of this class of cases, and enable them to live many 
months, or until the farther development of the coincident constitutional 
disease cuts them off. 

Diagnosis. — In giving the clinical history of acute and chronic pleuritis 
I have already directed your attention to the symptoms and physical signs 
that characterize each stage in the progress of all grades of the disease, 
close attention to which will enable you not only to determine whether 
pleuritic inflammation exists as distinguished from other affections, but 
also the stage of its advancement and the pathological consequences 
which may have resulted, more especially as regards the quality and 
quantity of accumulated inflammatory products. The affections most 
Jiable to be confounded with pleurisy are neuralgic pains in the inter- 
costal or phrenic nerves, acute and subacute rheumatic inflammation in 
the intercostal structures and diaphragm, and inflammations of the peri- 
cardium, spleen and liver. 

If you remember that the t\vo former are usually unaccompanied by 
increase of temperature and equally free from any abnormal sounds to be 
obtained by auscultation and percussion in any stage of their progress, 
while pleuritic inflammation involves both, you can hardly fail to differ- 
entiate the one from the other. The rheumatic inflammation may be ac- 
companied by some acceleration of pulse and febrile heat, but the pain is 
more continuous, less lancinating or sharp, and auscultation and percus- 
sion yield none of the ph} T sical signs that I have mentioned as accompany- 
ing the first and second stages of pleuritis. Inflammatory affections of 
the liver and spleen not only present symptoms chiefly located below the 
diaphragm and peculiar to those organs, but they fail to induce any phys- 
ical signs of disease in any part of the chest. While the general symp- 
toms, character of pain and physical signs are similar in both pericarditis and 
pleuritis, yet in the one they are synchronous with the action of the heart, 
and in the other with the respiratory movements. Very rarely, however, 
a case may be met with in which the inflammation will occupy that part 
of the left pleura connected with the pericardium and will give an audible 
friction with the movements of the heart. 

Treatment. — The objects to be accomplished in the treatment of acute 
pleuritis are the same that are presented to us in the treatment of acute in- 
flammation in any of the other tissues of the body. As I have explained 
in previous lectures the means for accomplishing these objects may vary 
some with the nature of the structure involved in the inflammation. 
When the structure involved is highly vascular, like that of the parenchyma 
of the lung, the indication for lessening vascular fullness or congestion in 
the first stage is predominant over all others. But when the structure 
involved in the inflammation is less vascular, composed more largely of 
connective tissue, like the serous membranes of which the pleura is one, the 
fulfillment of this indication is of less relative importance than that which 
relates to the removal of the morbid sensitiveness of the structure and 
the intensity of the pain. While in pneumonia, as I have stated in pre- 
ceding lectures, the degree of vascular engorgement in the first stag^e de- 
termines the amount of exudation in the second, which may directly ob- 
struct the function of oxygenation and decarbonization of the blood to 
such a degree as to endanger life; in pleuritis the exudation, whether 
serous or plastic, although occasioning inconvenience, causes no direct 
danger to life except in extreme cases. 

The intensity of the pain that the patient suffers, the voluntary stifling 
of respiration, and restlessness, are all effects which contribute much to 
prolong the disease. And yet, the practitioner should keep both these 



444 CHRONIC PLEUEUTIS. 

indications in view; namely, that of relieving the vascular fullness in the 
first stage of the inflammatory process, and of subduing pain and the 
morbid excitability of the structures, adjusting his remedies to the re- 
moval of both in accordance with their relative importance in each indi- 
vidual case. The accomplishment of the first indication, namely, lessen- 
ing the vascular fullness, may be effected by three classes of remedies; 
first, direct abstraction of blood by venesection or local bleeding; second, 
by arterial sedatives, which, by diminishing the heart's action, lessen the 
amount of blood taken to the inflamed part in a given time; third, by the 
use of evacuants, which, acting upon the bowels and kidneys, increase the 
discharges and thereby indirectly deplete the circulation. The accom- 
plishment of the second indication is most promptly and efficiently ob- 
tained by the judicious use of opiates. In the more severe cases of 
acute pleuritis, occurring in subjects previously healthy, and in the active 
period of life, characterized by sudden development of acute pain, fol- 
lowed rapidly by pyrexia or increase of temperature, full pulse, and dry 
skin, the most reliable and efficient treatment will be the opening of a 
vein and the abstraction of such an amount of blood as will cause a de- 
cided diminution of pain, lessen the fullness and tension of the pulse, 
and cause a little paleness of the features. Thus is produced within a 
few minutes that abatement in the symptoms and arrest of determination 
of blood to the inflamed part which would require several hours for 
accomplishment by the best cardiac sedatives. To hold the advantage 
thus gained, however, you should follow the venesection as speedily as 
possible, by the use of veratrum viride or aconite or a combination of 
veratrum viride and gelseminum in such doses, repeated w4th such fre- 
quency as to induce an early sedative effect — if possible, before reaction 
has taken place from the effects of the venesection. At the same time to 
relieve the pain and restlessness of the patient and overcome that element 
of the inflammatory piosess which consists in morbid excitability of the 
tixtures, such doses of some one of the preparations of opium, combined 
with an alterant, should be given between each of the doses of the seda- 
tive, as will completely control pain and keep the patient moderately at 
rest. 

For these purposes, probacy a combination of the sulphate of morphia 
in doses of two centigrams (gr. -^), with calomel six centigrams 
(gr. i), bicarbonate of sodium three decigrams (gr. v), given in the 
form of a powder with a little white sugar, and repeated every three or 
four hours, would accomplish the object as efficiently as anything that 
could be used. The veratrum viride or aconite that are given as seda- 
tives alternately with these powders, may generally be given in combina- 
tion with nitrous ether and liquor ammonias acetatis — which not on y 
make a good vehicle for the sedative but also exert some influence in 
promoting secretions from the skin and kidneys. In the great majority 
of cases, even of the most severe and acute attacks of pleurisy, one free 
bleeding, sufficient to produce the effects I have mentioned (it will usually 
require from twelve to twenty-four ounces of blood), followed by the rem- 
edies which I have indicated, will be found sufficient to overcome all the 
more active symptoms. It will make the patient more or less inclined 
to sleep, cause the pulse to become softer and more compressible. The 
skin will become somewhat moist by the end of the first twenty-four 
hours of the treatment. If this is the case, and on careful examination 
by auscultation and percussion, the friction sound of the first stage is 
either much diminished or removed, and the indications of effusion, such 
as increased dullness on percussion and absence of respiratory murmur 



TREATM ENT. 445 

do not indicate a very considerable amount of exudation or effusion, it 
will be sufficient to continue the cardiac sedative in moderate doses, sus- 
pend the use of the powders for the present and give in tbei. place a 
saline laxative sufficient to produce a moderately free movement of the 
bowels. After the bowels have been freely moved, if there is no returi 
of acute pain or restlessness, the patient may be put upon a prescription 
composed of nitrous ether, liquor ammonii acetatis and camphorated tinc- 
ture of opium, each sixty cubic centimeters (3 i i), and tincture of digitalis 
thirty cubic centimeters f r i), of which four cubic centimeters or an ordi- 
nary teaspoonful may be given every three hours in place of the previous 
cardiac sedative, and a dose of the compound powder of opium, ipecacu- 
anha and nitrate of potassium five decigrams (gr. viii), given at bed- 
time. These remedies, by continuing the action upon the skin and 
kidneys, and the powder at bed-time, by procuring rest, will usually ren- 
der the patient comfortable through the third, fourth or fifth days, while 
the moderate amount of effusion that had taken place is re-absorbed, leav- 
ing but little physical evidence of any accumulation in the cavity of the 
pleura. The patient is now convalescent, requiring but little additional 
care except to avoid exposure, subsist upon a mild diet, and avoid active 
physical exercise, until an ordinary degree of strength is regained. 

I have seen many cases of acute pleurisy occupying but one side of the 
chest, that under this management were completely relieved, and the 
amount of exudation either plastic or serous so limited as to lead to no 
serious embarassment of the respiratory function in any part of its prog- 
ress. But to insure this success it is necessary that the treatment be 
commenced actually during the first stage of the inflammatory process, 
which, as I have already stated in giving the clinical history, lasts usually 
not more than twelve or eighteen hours after the initial chill and symp- 
toms of the attack. But in some cases, notwithstanding the early and 
judicious use of the remedies I have indicated, on the second and third 
days of the treatment it will be found that the pain, although much 
abated, is nevertheless quite sharp whenever the patient attempts full, 
breathing or any freedom of bodily motion; that the temperature con- 
tinues more elevated and the physical 'signs of exudation and effusion 
rather more marked. Where this is the case I add to the foregoing treat- 
ment counter irritation by blisters. The application of a blister four by 
six inches over the most painful part of the affected side will very fre- 
quently afford great relief, and in conjunction with the other remedies will 
arrest the further progress of the inflammatory process, leading to the 
early re-absorption of the effusion that exists in the cavity of the pleura. 
In the milder cases of acute pleurisy, or those occurring in subjects less 
vigorous, or weakened by any previous constitutional impairment, the 
abstraction of blood by venesection is usually unnecessary and inexpedient. 
In some of them local bleeding by leeches or by cupping may still afford 
decided aid in the early stage of the disease, but, omitting the bleeding, 
such cases may be overcome sufficiently early by the use of the other 
agents that have been recommended. 

Again, the cases in which you will be called, where the first stage of the 
disease has already passed by, and when you find on your first examina- 
tion of the patient that instead of the friction sound you have decided 
dullness on percussion, in most of them increased fremitus of voice and 
absence of the respiratory murmur, constituting evidence of decided 
effusion, no idea of abstraction of blood either by venesection, leeches or 
cupping should be entertained, as that would only serve to deplete the 
patient withcut any beneficial effect upon the progress of the disease. 



416 CHRONIC PLEURITJS. 

The treatment now should be commenced with a view of arresting the 
further effus.on of serum or exudation of plast'.c material on the one hand, 
and of hastening the re-absorption or removal of what has already taken 
place on the other. For these purposes open the bowels by a mild saline 
laxative, administer every three or four hours the mixture which we 
have already mentioned, consisting of nitrous ether, liquor ammonii 
acetatis, camphorated tincture of opium and digitalis, to which we may 
now add iodide of potassium in such proportions that the patient will get 
three decigrams (gr. v) of the latter in each dose. Apply a blister at 
once to the affected side of the chest, and if the effusion appears slow in 
diminishing, the blistering may be repeated two or three times at inter- 
vals of three or four days. Under these measures the great majority of 
cases, although having passed the first stage before they are brought un- 
der treatment, will begin to improve and continue slowly to do so, until 
the removal of the effused fluid, the re-expansion of the compressed lung 
and the establishment of convalescence have taken place. But in many 
of them it will require two to four and sometimes six weeks to accomplish 
this end. In those cases which are sometimes met, in which the amount 
of the effused fluid in the cavity of the pleura is so great as not only to 
completely compress the lung on the affected side, but to crowd the 
mediastinum in the opposite direction, lessening also the space for the 
expansion of the other lung, thus causing the patient to suffer the severe 
consequences of imperfect aeration of the blood, causing a distressing sense 
of suffocation and inability to lie down, it is not proper to wait for the 
slow process of absorption of the effused fluid. The practitioner should 
proceed at once to relieve the suffering and danger to which the patient 
is exposed by the removal of the effused fluid with the aspirator; a 
method which is usually safe and easily practiced. There is another mo- 
tive in such cases for proceeding at once to withdraw the effused liquid, 
and that is to avoid the danger that would occur from keeping the lung 
long compressed until it had become bound in this position by a covering 
of false membrane. If this is permitted, there would remain after the 
patient's recovery in other respects, a permanent impairment of the 
capacity of that lung, a shrinking of that side of the chest, constituting a 
deformity, and making the patient more liable to subsequent degener- 
ation of the lung, and would ultimately shorten life. 

There is another class of cases in which, though the effused fluid is not 
so much in quantity as to produce direct danger from suffocation, yet is 
sufficient to closely compress the lung on the affected side, and in which, 
from the previous healthy condition of the patient, we have reason to 
suppose that there is a liberal amount of plastic exudation covering the 
compressed lung in addition to the effused fluid. 

In these cases re-absorption, under ordinary treatment, takes place very 
slowly, thereby indicating clearly that to wait for the completion of the 
process would require several weeks of time and as has been explained, 
would render probable the permanent binding of the lung in this compressed 
condition. Under these circumstances it is the duty of the practitioner to 
aspirate the chest. This may be done slowly at one operation, giving Mie 
patient time to inflate the lungs as the process of drawing off the fluid is 
very gradual, or only a part of the fluid be removed at one time; delay 
twenty four hours and then another part may be taken, until the whole is 
removed in successive punctures thus giving opportunity for the com- 
pressed lung to regain its expansion in proportion to the removal of the 
compression. You will notice that in speaking of the most active and 
severe cases in the first stage, I have mentioned the use of a powder con- 



TREATMENT. 447 

Bisting of the sulphate of morphia, calomel and bi-carbonate of sodium. 
The chief object of giving that powder, aside from the anodyne effects of 
the morphia, was to induce the early effect of the mercurial in conjunc- 
tion with the bi-carbonate, in lessening the plasticity of the inflammatory 
exudate. In other cases which are sometimes met with, though rarely, 
in which the exudation is almost entirely plastic, there is not apt to be in 
the second stage of the disease sufficient serous exudation or material to 
compress the lung, but a copious plastic exudation continues to modify 
the friction in the second stage, usually leading to extensive adhesions of 
the two surfaces of the pleura together. In sue i cases the free use of 
the carbonated alkalies internally, and efficient alterative doses of the 
mercurial as far as will be borne without producing a visible effect upon 
the patient's gums or breath, and then following the mercurial by moder- 
ate doses of the iodide of potassium in addition to the carbonated 
alkalies will be more efficient than any other treatment in first ar- 
resting the accumulation of these plastic exudates, and subsequently in 
h stening their disintegration or, at least, partial removal. But most of 
such cases to which we give efficient alterant and alkaline treatment, with 
blisters externally, though recovering well, will leave more or less perma- 
nent adhesion of the surfaces of the pleura to each other. These adhesions 
usually cause a feeling of constraint en taking a full inspiration and 
sometimes a slight sense of soreness for a considerable time after conva- 
lescence, but ultimately become attenuated and smooth by the continued 
motions of the chest. And although they may continue through the subse- 
quent life of the patient they will usually create little or no inconven- 
ience. 

In the management of ordinary cases of acute pleurisy the patient 
should be kept at rest in the first stage, and a very mild, simple diet, con- 
sisting chiefly of milk and animal broths given in small quantities. In 
the second stage, a little more liberal amount of nourishment and simple, 
cooling drinks are all that are required. Occasionally one of the most 
acute class of cases, during the first two or three days, will present a 
temperature so high that antipyretic measures, more especially free 
sponging of the surface with cold water, or even wrapping the chest and 
body in a wet sheet, will be advisable and productive of much relief. 
But in the great majority of cases these special antipyretic measures are 
not necessary. As you are aware, during the last quarter of a century, the 
practice of venesection in almost ail diseases has been so nearly abandoned 
and the use of opium for overcoming inflammations, even of an acute 
character, so generally commended, that you may d.,ubt the expediency 
of the recommendation I have made, to commence the treatment of the 
more acute cases in the first stage with a free venesection. You may be 
induced to disregard that full, tense pulse, rapid development of temper- 
ature, giving severe pain and stifled breathing, which indicate the true 
sthenic acute inflammatory process, and attempt to subdue such cases 
simply with opiates and cardiac sedatives without the abstraction of blood. 
In the larger proportion of cases I admit that you can succeed; but in 
many of them, while you succeed in the end, the time required is much 
longer, the amount of effusion and compression of the lung is greater, the 
patient is subjected to greater danger of secondarv consequences of a 
bad character, and occasionally an instance is met with in which the at- 
tempt to administer full doses of opium, without first lessening the arterial 
tension, is followed by direct aggravation and increase of all the symp- 
toms. A case of this kind occurred under my own observation many vears 
since. A strong laboring man, about twenty-five } T ears of age, of a 



448 PLEURITIS. 

sanguine temperament, accustomed to daily labor, was attacked with all 
the symptoms of acute pleurisy in the latter part of the afternoon while at 
his work. The pain was so severe that it was with difficulty he could 
reach his home. On his way he stopped at my office for advice. Having 
just read some accounts from high authority of the ability to subdue acute 
inflammation of the serous membranes by full doses of opium, I or- 
dered for this patient six powders, each containing thirteen centigrams 
(or. ii) of powdered opium and three decigrams (gr. v) of nitrate of potas- 
sium, with instructions to take one of them as soon as he reached his 
home, and to repeat the dose every two hours, till his pain was subdued. 
In about eight hours I was called in great haste to see him, and found 
the patient wildly delirious, face deeply suffused with redness, pupils 
small, head hot, pulse full, and requiring two persons to keep him in his 
bed. He had taken the fourth powder of his opium and nitrate of potas- 
sium with no other effect than to have each powder followed by increase 
of the delirium and fever. I immediately opened a vein in his arm, letting 
the blood flow in a full stream, and when 1 had taken about one liter 
(?xxx) of blood he became calm, free from delirium, pulse soft, and a 
little moisture started out upon his forehead and face. 

As I stopped the flow of blood some sensation of syncope, sufficient 
to bring a full sweat over the surface, ensued. I told the attendants 
to continue his powders, one every four hours, and left him. The result 
was, he passed into a quiet sleep, remained so for four or five hours, 
sweating freely, and the following day was found almost free from fever, 
no continuous pain in his side, and but moderate stitches of pain in at- 
tempting to take a full breath, but there was some degree of dullness of 
the left side of the affected part of the chest and absence of respiratory 
murmur sufficient to indicate a moderate degree of effusion. His bowels 
were opened by a saline laxative, light counter-irritation applied over the 
affected side, the patient kept at rest for two days, and his convalescence 
was complete. I relate this case to show the difference between the effects 
of administering opiates at once with a tense, hard pulse, in the beginning 
of acute inflammation, and the effects of the same remedy when through 
lessening the amount of blood in the vessels, that arterial tension has been 
removed and the whole tone of the vascular system put in a different re- 
lation. I have seen the same practical point illustrated a hundred times 
in an equally striking manner, and I feel entirely safe in assuring you 
that } t ou will do far better justice to your patient in all similar cases of 
inflammation, if you sacrifice a sufficient amount of blood by venesection 
when he comes under your care in the early period of the most acute 
stage, and in milder cases procure free evacuation of the bowels and give 
cardiac sedatives for a sufficient time to lessen the vascular tension before 
full anodyne doses of the opium are administered. The directions I have 
given you thus far relate to the management of acute pleurisy as it is 
met with usually, in the field of general practice; but there are some de- 
viations from the ordinary class of cases which will require modification 
in the treatment. When the inflammation occurs in subjects previously 
in bad health, either from scrofulous, tuberculous or syphilitic influences, 
or constitutional impairment, there is much tendency to exudative mate- 
rial of a purulent character, which may fill the pleural cavity with a 
sero-purulent or purulent fluid, neither of which would be capable of 
absorption. 

The occurrence of suppuration in the progress of pleuritic inflammation 
of an acute character is usually indicated by the occurrence of chills during 
the third, fourth or fifth days, followed by a brief exacerbation of fever and 



TREATMENT. 449 

copious sweating. These periods of sweating are apt to recur at irregular 
intervals. The patient loses strength and flesh rapidly, the pulse becomes 
soft, weak, quick, and we have all the physical signs of pretty rapidly in- 
creasing accumulation of fluid in the pleural cavity. The supervention 
of such symptoms should always lead to the suspicion of suppuration, and 
consequently either an entire pus accumulation in the pleural cavity con- 
stituting empyema or pyothorax, or an accumulation of a mixture of serum 
and pus, which in either case will not be absorbed or removed by any 
spontaneous process. Consequently it is in vain to lose time by the use 
of remedies calculated to promote absorption. It is not only in vain, but 
the delay thus occasioned greatly increases the risk of loss of life. Just 
as soon, therefore, as the evidences of accumulation are sufficient to indi- 
cate any considerable compression Of the lung, the aspirator needle should 
be introduced for the purpose of making certain the diagnosis. If on 
withdrawing a small amount of the fluid, it is found to contain a large 
proportion of pus, the only safe practice is to freely aspirate what can 
be drawn off with the aspirator, and to enlarge the opening so as to allow 
judicious drainage, accompanied by the use of antiseptics, as you will 
rind described in all your surgical works, for the treatment of empyema 
and other internal collections of pus. At the same time the patient 
must be supported by mild tonics, easily digestible nourishment, rest and 
pure air. Such measures, judiciously applied, will, in many cases, lead to 
the recovery of the patient. But in some, especially w T hen complicated, 
as they are apt to be with tubercular deposits in the lungs, the recovery 
will be only partial. The patient will linger, in some cases, for many 
months in a feeble condition, while the disease in the lung tissues pro- 
gresses through its successive stages, and aids materially to reduce the 
patient and hasten the fatal result. 

The same remarks in regard to treatment are applicable to those cases 
of circumscribed pleuritis of a subacute character that are apt to recur, 
sometimes rapidly, in the progress of cases of tuberculosis in which the 
tubercular deposits are near the surface of the lung. Some of these are 
mild and will rapidly yield to the prompt use of anodynes, aided by the 
cautious use of cardiac sedatives, but will generally recur from time to 
time until they end in suppuration, frequently leading to a communication 
of the softened tubercular abscess in the lung through the pleural mem- 
brane so as to make a communication between the tuberculous abscess 
and the pleural cavity. In these cases free opening, drainage and anti- 
septics, with supporting measures internally, constitute the only means 
of palliating the condition of the patient and prolonging life. In some 
of this class of cases the communication between the suppurative cavities 
in the lung and the cavity of the pleura allows of the escape of air, and 
we get complicating what was otherwise a pyothorax or accumulation 
of pus, a pneumothorax, or accumulation of air, in the pleural cavity, 
giving, at the more dependent part of the affected side, dullness on per- 
cussion, and symptoms of accumulation of fluid, while we have tympanitic 
resonance from the presence of .air above, Uuless the accumulation of 
air and matter is so great as to threaten the life of the patient by the de- 
gree of compression, it is better, in most such cases, to palliate the pa- 
tient's condition as much as possible by tonics, anodynes and rest, without 
attempting the more radical measure of incision and drainage on account 
of the possibility of making a communication between the air that enters 
the lungs and the exterior, a means of encouraging collapse and sudden 
death: although such results do not by any means always follow when the 
communication exists. 

29 



450 PHTHISIS. 

The treatment of chronic pleurisy miy be summsd up in a very few 
words. All that I have said in regard to the measures required for limit- 
ing the amount of effusion and exu iation in the second stage of an acute 
attack, and for the subsequent removal of such effusion either by absorp- 
tion or by aspiration in cases of moderate effusion, and free openings and 
drainage when the effusions are purulent, are equally applicable to the 
treatment of chronic pleurisy; the difference being mostly, that, in 
chronic cases the progress is slower, the accumulations take place much 
less rapidly, accompanied by little fever; and although the measures of 
relief are the same in kind so far as the administration of medicines is 
concerned, they require to be given with a less degree of energy. 



LECTUEE XLVI. 



Phthisis Pulmonalis or Pulmonary Consumption— Its varieties— Their clinical history, Anatom- 
ical changes, Diagnosis, and Prognosis and Treatment. 

GENTLEMEN: Varieties.— Under the head of phthisis pulmonalis, or 
wasting disease of the lungs, are included at the present time sev- 
eral diseases essentially distinct from each other in their origin and 
the causes which produce them, although leading to very nearly 
the same ultimate results. If we keep in view the different patho- 
logical conditions which give rise to those symptoms and lesions 
usually denominated consumption or phthisis pulmonalis, we shall 
;find three distinct varieties of disease. First, those cases which 
are accompanied by primary deposits in the pulmonary tissues con- 
sisting either of small miliary granules, called miliary tubercles, of a gray- 
ish color, or of larger masses of a more yellow hue, and beginning in- 
siduously without symptoms of an inflammatory character, and even with 
so little local feelings of irritation or annoyance to the patient that their 
existence is not suspected until considerable progress has been made. 
This variety of disease is properly styled pulmonary tuberculosis. The 
second variety includes those cases in which the deposits or accumulations 
in the lung tissue date their beginning either from pulmonary hemor- 
rhage or more frequently from an attack of pneumonia. Tnere is a class 
of patients not infrequently met with who are hereditarily predisposed to 
tuberculous or scrofulous disease, or having the predisposition acquired 
from circumstances relating to habits of life and sanitary conditions, who, 
although not having any deposits or change in the lung tissue at the time 
that they are attacked with acute pneumonia, nevertheless when thus at- 
tacked, the exudation which accompanies the pneumonic inflammation 
partaking of the abnormal properties belonging to the previous diathesis, 
fails to be disintegrated and removed by resolution on the subsidence of 
the inflammatory process. The exudative material which is thus left in 
the lung in such cases very generally, within a period ranging from three 
to four weeks to as many months, is found to be undergoing a deteriora- 
tive change called caseous degeneration. In the progress of this change, 
the patient begins to manifest quickness of pulse, increase of temperature 



VARIETIES. 451 

especially in the afternoon and evening"., renewal of cough and oTten early 
supervention of night sweats. This class of cases are liable to ran a more 
rapid course, both in the conversion of the caseous deposit into purulent 
material, and in the establishment of suppurative inflammatory action in 
the contiguous lung tissue, than the cases winch are of a primary tuber- 
culous origin, and we may distinguish them from the first by designating 
them caseous phthisis. 

The other variety of disease generally included under the head of 
phthisis pulmonalis is strictly of a fibroid character; and generally, if not 
always, originates from primary capillary bronchitis. The capillary form 
of bronchitis in which the congestion, thickening and hardening of the 
lining membrane of the smaller bronchial ramifications is sufficient to close 
many of those tubes and to exclude the air from the alveoli or cluster of 
cells at their termini, causing the latter to collapse, thereby tends to dimin- 
ish the capacity of the lung for air, and more or less to interfere with the 
movement of the blood in the capillary net- work surrounding the collapsed 
cells. This frequently leads to more or less exudation from the obstructed 
capillaries and increased irritability of the connective tissue of the lung, 
constituting a grade of inflammatory action, similar to that in the lin.ng 
of the bronchioles, which constituted the original disease. At first the 
number of the alveoli thus deprived of air and collapsed may be small 
and lead to but little inconvenience. As this grade of bronchitis is 
generally renewed with every cold season of the year or exposure of the 
patient to cold and damp air, and as each renewal is liable to obstruct an 
additional number of the smaller bronchial ramifications, thereby increas- 
ing the number of collapsed cells and the amount of exudation and scle- 
rosis of the connective tissue surrounding them, in the end, the whole side 
of the chest involved, or both sides if the bronchitis involves both lungs, 
becomes shrunken, and from the diminished amount of air, gives less res- 
onance on percussion than natural, increased fremitus of voice, not in- 
frequently hemorrhages and the establishment in the sclerosed connective 
tissue of a suppurative process, which causes a muco-purulent expec- 
toration, general wasting of the flesh and strength, and the final estab- 
lishment of hectic, night sweats, and all the phenomena of the advanced 
stage of phthisis, or consumptive disease. 

In a preceding lecture, when discussing the different grades of bron- 
chitis, their clinical history, pathological changes and treatment, I stated 
all that may be necessary in regard to this latter class of cases (see pp. 396- 
7), and in the lecture upon pneumonia and its results, I gave sufficient ac- 
count of the symptoms and progress of the caseous form of phthisis. (See 
p. 433.) It remains, therefore, at the present hour, to direct your attention 
chiefly to the tubercular phthisis, as we have indicated, originating from 
the tubercular diathesis, either hereditary or acquired, and without any 
necessary connection with inflammatory attacks. The scrofulous and tu- 
berculous diatheses, so far as regards their etiology, general symptoms, and 
the treatment which they require, both hygienic and medical I presented 
to you in sufficient detail when speaking of the chronic general diseases 
(see Lectures XXVII, XXVIII), and consequently I need not repeat with 
any degree of fullness the primary causes which lead, first, to the formation 
of the diathesis and the alteration of the constitutional condition, and sec- 
ondly, to the establishment of local manifestations of disease in the form of 
caco-plastic deposits in the lungs. It is sufficient to recall your attention 
to the fact that when the diatheses, which are denominated scrofulous and 
tuberculous, are once established, t". ere is a tendency to the development 



452 PHTHISIS. 

of imperfectly elaborated material constituting imperfectly formed cells, 
granules, more or less amorphous matter, accompanied by certain inor- 
ganic material, and when these materials are thus elaborated in the sys- 
tem they appear to be incapable of disintegration and elimination as ex- 
cretory matter on the one hand, and equally incapable of being added to 
any of the normal tissues of the body so as to form natural repair or 
growth. Being neither used to increase the growth of any natural tissue 
nor susceptible of elimination, the tendency is to find lodgment or de- 
posit in some of the structures of the body. As a general rule they will 
be more likely to be found deposited in such structures as are most highly 
vascular, and at the same time subject to the greatest variations in the 
movement of the blood through the vascular tissue. 

In very early childhood, while the brain is less mature in its develop- 
ment than most of the other organs, strong hereditary diatheses in this 
direction often result in the deposit of the granular tubercle in the mem- 
branes and periphery of the brain. A little later, anywhere between 
childhood and puberty, perhaps the greater tendency is to find lodgment 
in the lymphatic glands and adenoid structures of the body. From the 
period of puberty to the middle period of adult life, far the greater tend- 
ency is to find lodgment for this material in the pulmonary structure. 
And, as abundant clinical observation has shown, the deposition com- 
mences, in far the larger proportion of cases, at or near the apex of the 
lung. It may commence simultaneously upon both sides, or it may in- 
vade but one side first, subsequently involving the other/ or it may attack 
but one side in any part of its course. Having already described suffi- 
ciently the symptoms, progress and diagnostic features of the tuberculous 
diathesis prior to the actual deposit of the tubercular materials, I will 
direct your attention at once to the symptoms and clinical history of the 
local development and progress of tubercular disease of the lung. 

Symptoms. — A great majority of these cases are characterized during 
the first weeks, and sometimes months, of their progress by no other re- 
cognizable symptoms than a very gradual loss of flesh, diminution of color 
or increasing paleness, slight shortness of breath on active exercise or 
going quickly up stairs, slight increase in the frequency of the pulse in 
the afternoon and even'ng, and an increase of one or two degrees of 
temperature during the same periods of the day. These changes are so 
gradual in their development, give rise to so little inconvenience to the 
patient that they often attract from him no attention. But after a period 
varying from six weeks to six or eight months in some instances, an acci- 
dental exposure to cold and wet induces a mild attack of bronchitis ac- 
companied by the usual symptoms of cough, soreness in the chest, slight 
fever and the ordinary characteristic expectoration. The patient and his 
friends regard it as a simple cold. It passes through its usual stages to 
the period when an ordinary bronchitis declines.and disappears. But the 
cough, instead of disappearing, becomes less active and less frequent, and 
generally is restricted to the time that the patient rises from bed in the 
morning or first lies down at evening. The expectoration which had been 
the usual expectoration of moderate bronchitis begins to show more of a 
yellowish tinge, especially in the central part of the expectorated matter 
whenever deep coughing occurs or when the patient coughs freely after 
sleeping through the night. The soreness in the chest, that had charac- 
terized the attack of bronchitis, disappears. 

But in addition \o the continuance of cough, the patient gradually, 
from week *o week, loses color and flesh, and becomes more conscious of 
sc^ae shortness of breath on active exercise. If the case is allowed to 



SYMPTOMS. 453 

take its own natural course, the cough will increase moderately from week 
to week, and the expectoration, especially in the morning, will become 
more and more of a purulent character, some portion, if not all, tending to 
sink in water. Not infrequently slight hemorrhages occur. The patient's 
appetite becomes less, boweis often incline to be costive, pulse in the 
morning soft, easily compressed, but little if any more frequent than nat- 
ural, face and lips pale, but in the last half of the day and evening more 
color appears in the face, pu!se becomes accelerated to ninety-five or a hun- 
dred in the minute, respirations a little more frequent than natural, but 
shorter and of less depth in proportion to their frequency. The patient 
somewhat troubled with cough on lying down, gets quiet after a little and 
usually sleeps without much disturbance till between four and six in the 
morning, when he awakes with increase of coughing and expectoration, 
and sometimes finds that during the last of his sleeping hours a general 
perspiration had supervened. Sometimes this morning paroxysm of 
coughing comes as early as three o'clock, and after lasting half or three 
quarters of an hour, the patient will fall asleep, and if left undisturbed 
may then rest till seven in the morning, when, on attempting to rise, he 
will suffer more paroxysms of coughing and expectoration of a purulent 
character. 

These are the general symptoms which accompany the early stage of 
tuberculosis up to the time of what is denominated the commencement of 
the second stage of the diseasa. But if its progress is not interfered with, 
from this time the symptoms I have last described consisting of paleness, 
weakness, languor and 1 »w temperature in the morning, followed by flush 
of the cheeks, increased temperature, acceleration of pulse, shorter and 
more frequent respiration, with steadily increasing emaciation and diminu- 
tion of strength, will continue with accelerated pace from week to week 
and from month to month. At the same time the expectoration increases 
in quantity, and a larger proportion of it is of a purulent character, some- 
times mixed with a little blood. The patient may have hemorrhages of a 
greater or less amount of clear blood, unmixed with mucus or matter, at 
any part of this or the preceding stage; and the occurrence of night 
sweats usually becomes more frequent and copious, till at the end of from 
three to six months, as an average, the patient is obliged to forego further 
exercise and take to his bed, or at least to his room. The subsequent 
history is simply a continuance of the prominent symptoms of emacia- 
tion, hectic fever, night sweats, often accompanied after awhile by en- 
tire loss of appetite, the occurrence of apthous ulcerations in the mouth 
and fauces, short frequent turns of diarrhoea generally without griping or 
pain, more rapid exhaustion, cold extremities, loss of voice, or feebleness 
of articulation, extremely rapid and weak pulse, breathing short, hurried, 
imperfectly inflating the lungs, and finally collapse and death — the history 
covering a period of time varying from six months to two or three years. 
You will notice from the history I have given you that the clinical prog- 
ress of the disease may be divided into three stages. The first is that of 
simple crude tubercular deposit, occasioning but slight symptoms of any 
local trouble, and varies in its duration from four weeks to double that 
number of months. 

The commencement of the second stage is marked by evidences of in- 
creased inflammatory action and hyperemia in the lung, causing more 
cough, temporary periods of soreness in the chest, acceleration of pulse, 
and moie expectoration. The supervention of the symptoms are usually 
attributed by the patient to taking cold and if they are mitigated by 
treatment for a time they are renewed; and each renewal will be attrib- 



454 PHTHISIS. 

uted as the first to some accidental cause, but generally they are owing 
merely to the natural progress of the disease in the lung. This second 
stage, commencing as I have indicated, continues till the suppurative proc- 
ess, softening of the tubercular masses, and establishment of the suppu- 
rative process in the contiguous lung tissue is complete; as indicated by 
decided purulent expectoration, hectic fever and night sweats. This sec- 
ond stage pathologically is the stage of softening disintegration of the 
tubercular masses, and the establishment of the suppurative process. The 
third stage commences with the completion of this suppurative process, 
the excavation of one or more tuberculous cavities, and well marked 
hectic fever. Thus far I have given you only the subjective symptoms 
that accompany the progress of the disease and, although in most cases 
sufficient by themselves to render the diagnosis reasonably certain, they 
should never be relied upon to the neglect of physical examination of the 
chest. In the first stage, that of primary tuberculosis of the lung, in- 
spection of the chest will usually show some degree of flattening in the 
infra-clavicular region or lessening of the antero-posterior diameter of the 
upper part of the chest. This, in the very early stage, is often hardly per- 
ceptible. But if the tubercular deposits have continued even in an entire- 
ly latent condition for a few months, this change is almost always easily 
observable on inspection, and is made still more apparent by stretching a 
tape line from the most prominent part of the clavicle to the nipple, which 
will show a receding or flattening, from the fact that the skin over the 
second and third ribs will not reach the tape line, but fall from it enough 
to indicate a concavity, where there should be a convexity of the chest. 
When the tubercular deposit exists in only one lung the contrast between 
the affected side in this respect and the other is usually well marked. 

Percussion carefully practiced in such manner as to elicit the tone 
of sound distinctly and clearly, will, in almost all cases, indicate an ap- 
preciable diminution in the resonance of the affected side of the chest, in 
the infra-clavicular space. In cases where the tubercular deposit is small 
or diffused through a considerable portion of the upper lobe of the lung, 
the diminution of the resonance may be so slight as to leave you in doubt 
as to whether it is less than natural. But, even in those cases, if in ad- 
dition to testing the resonance carefully by percussion, you examine the 
degree of fremitus of voice with the aid of a double tube stethoscope you 
will be able to detect increased fremitus or vibration through the wails 
of the chest sufficiently to corroborate even the slightest diminution 
of resonance by percussion. Of course, the more the deposit accu- 
mulates in the lung, the greater will be the fremitus and the less 
will be the resonance. Auscultation in this first or primary stage 
of tuberculosis seldom gives to the ear any new sounds or rales, 
but simply modifications of the natural respiratory or vesicular 
murmur. These modifications of the natural murmur consist chiefly in 
altering the uniformity of the inspiratory sound, rendering it often irreg- 
ular in its development, and causing a renewal of the murmur in each 
expiratory act. In some instances the change consists in simply shorten- 
ing and rendering the natural murmur deficient. On the other hand, 
when the mass of tubercular deposit is larger, the sounds transmitted 
through the condensed pulmonary tissue will be increased above the 
natural intensity, and not infrequently present the quality that is 
called tubular. The physical signs of the first stage of tuberculosis, 
therefore, are not the production of new sounds, but simply alteration of 
the natural respiratory murmur, increased fremitus of voice and dimin- 
ished resonance on percussion. 



SYMPTOMS. 455 

These physical signs, taken by themselves, do not prove the existence 
of tuberculosis, they simply prove the existence of something which has 
diminished the amount of air in the lung under examination, and thereby 
rendered its structure more dense. Whether that density is from tubercular 
deposit, pneumonic exudation, pulmonary oedema, or compression from 
pleuritic effusion, must be determined by the history of the case, and the 
associate general symptoms, as we shall see when we come to speak more 
particularly of diagnosis. In the second stage of tuberculosis, auscul- 
tation still gives alterations in the respiratory murmur, especially that 
which consists in irregularity in the development of inspiratory sound, or 
its renewal in expiration, and usually there are added more or less moist 
r&les. At first these rales will be movable, caused by mucus accumulat- 
ing more or less in the bronchial tubes and the passage of air to and 
fro through it. The rales consequently w'ill differ much in the amount 
present or absent at any particular moment, depending upon the 
fact as to whether the patient had been long without coughing and clear- 
ing the air passages, or had just before the examination, by such act, re- 
moved what mucus had accumulated. But as the second stage progresses 
and the tubercular mass becomes softened and the surrounding; iuno; tis- 
sue filled partially by a low grade of pneumonic engorgement, a sub- 
mucous rale is developed of a more fixed character, that is not removed 
temporarily by the act of coughing, but is developed regularly near the 
end of each moderate attempt at inspiration; showing that it' depends 
upon the entrance of air into texture filled more or less with a viscid 
fluid. 

It is especially distinctive of the early stage of suppurative softening 
in the progress of tubercular diseases. While auscultation reveals these 
changes in the second stage of the disease, percussion elicits a greater 
degree of dullness than in the first stage, and there is also a corresponding 
increased vibration of voice, making what was slight and perhaps a little 
obscure in the first stage, plain and unmistakable in the second. In the 
third stage of the disease, when the suppurative process is complete, when 
some of the abscesses now in the lung are evacuated, forming the com- 
mencement of suppurative cavities, auscultation still will leveal a fixed 
moist rale that sounds still more like forcing air into a porous body filled 
with a viscid fluid, accompanied by an occasional drop, as though two 
surfaces moistened with thick fluid had been separated from each other. 
Over these places the voice now instead of giving simple fremitus or in- 
creased vibration gives more or less distinct pectoriloquy or direct 
transmission of the voice into the ear or funnel of the stethoscope. 
Percussion over most of the affected part of the lung will still be decid- 
edly dull. If, however, cavities have formed near the surface of the lung 
it will sometimes happen that directly over the cavity, instead of dullness, 
there will be a modified tympanitic resonance. This is only when the 
cavity is large and near the surface. In other instances the cavity thus 
formed and communicating by a pretty free opening with one of the 
larger bronchial tubes, will yield on percussion directly over it, not a 
tympanitic resonance, but a peculiar sound denominated "Bruit du 
pot fele" or cracked metal sound. 

These are the physical signs which characterize the advanced or com* 
plete suppurative stage of tuberculosis. They are almost always most 
marked in the upper part of the chest. Rare cases occur, however, in 
which the tubercular deposits have taken place in the middle lobe of the 
lungs, and still rarer instances where they have been found to commence 
in the lower lobes and to produce the same successive changes in the gen- 



453 PHTHISIS. 

oral symptoms and physical signs as I have described, except that the 
sinking or flattening of the chest at the upper part would not be notice- 
able so much as the parallel changes in the middle and lower portions. 

I have thus traced the symptoms and physical signs of the different 
stages of tubercular disease with sufficient minuteness to give you a 
fair outline of its progress. There are some individual symptoms, 
however, to which it may be well to refer a little more in detail. 
Chief among these are hemorrhages. Hemorrhage as a symptom of 
tuberculosis is of importance, both in its effects upon the patient and as 
an aid to diagnosis. So far as my observation goes, pulmonary hemor- 
rhage is of very rare occurrence disconnected from prior tubercular de- 
posit. I am well aware that Niemeyer and some other recent writers, 
claim that pulmonary hemorrhage not infrequently precedes tubercular 
deposit, and is the cause of such deposit instead of being always second- 
ary. These writers claim that the hemorrhage is liable to occur without 
being preceded by any mechanical impediments from tubercular deposits, 
and when the hemorrhage takes place, more or less of the blood extrav- 
asates into the interstitial spaces of the tissue and part of it fails to be 
disintegrated and removed by absorption. Remaining, it undergoes 
caseous degeneration associated with more or less inflammatory conges- 
tion of the surrounding pulmonary tissue. These primary deposits soon 
change still further into a purulent condition, and the hyperemia of the 
surrounding tissue assumes the form of suppurative inflammation, thus 
giving you all the phenomena of a tubercular development in the second 
stage of its progress. I must acknowledge, that through a long period 
of observation, with the attention, during the later years, directed to this 
particular point, I have not been able to satisfy myself that a single case 
has come under my observation in which the hemorrhage preceded evi- 
dences of more or less tubercular deposit. And I am strongly inclined to 
think, that if such cases occur, they are extremely rare, and that the oc- 
currence of hemorrhage without any traumatic lesion or other special 
known cause, spontaneously proceeding from the pulmonary tissue, con- 
stitutes very strong presumptive evidence of latent tubercular disease. I 
have yet to find a patient whose subsequent history did not corroborate 
the position that hemorrhage is secondary and not primary to the tuber- 
cular formation. 

There are three pathological conditions connected with tuberculo- 
sis, that give rise to hemorrhage. The first would appear to be simply 
obstruction of the capillary or smaller blood vessels by the mechanical 
pressure of a primary tubercular deposit, damming the blood and causing 
the coats of the engorged vessels to rupture, thus allowing the blood to 
escape into the air cells and alveoli, from these through the bronchial 
ramifications to appear in the expectoration. Hemorrhage from this 
pathological condition usually takes place early in the progress of the tu- 
bercular disease, and is quite as apt to occur when the patient is entirely 
at rest, occasionally waking him from sleep in the night. Sometimes it 
appears while he is sitting at ease, at others while walking or standing, and 
not infrequently it is the first symptom that alarms the patient and cre- 
ates the suspicion that he has serious ailment. In most instances 
the quantity of blood lost is slight. It may be but a single 
mouthful, but in rarer instances it may come up mouthful after mouthful 
as fast as the patient is capable of spitting it out, with but little effort at 
coughing, till from two to four or six ounces are lost. Very much more 
frequently, however, the quantity will not exceed two or three drachms. 

The second pathological condition liable to give rise to hemorrhage 



SYMPTOMS. 457 

usually develops with the early part of the second stage of the tubercular 
disease, when the tissues surrounding the tubercular deposit f.rst begin 
to take on inflammatory action and the vessels become engorged with blood 
or hvpenemic. It not infrequently happens that at this stage some of 
the vessels immediately surrounding the tubercular mass have become 
weakened by more or less degeneration of the connective tissue entering 
into their coats. Consequently with th:j accumulation of blood at this 
stage the weaker points of the vessel yield to the distension and allow 
more or less escape of blood, and consequently of hemorrhage similar to 
that I have already described. These turns of hemorrhage also usually 
come without any special cause or physical exercise on the part of the pa- 
tient. The hemorrhage may be but a single one that marks this stage, or the 
escape of blood may take place rapidly at short intervals lasting through 
three or four days at a time and be renewed again in one or two weeks, or 
it may occur but once in the whole progress of the case. The third 
pathological condition liable to give rise to hemorrhage is the impairment 
and destruction of vessels in connection with the completion of the sup- 
purative stage and the formation of suppurative cavities in the lung. 
Hemorrhages at this stage are not so frequent as at either of the other 
stages mentioned; but when it does occur it is liable to be much more 
copious and sometimes by its quantity and the previously debilitated con- 
dition of the patient directly induces a dangerous degree of exhaustion. 
It is rare that it induces a direct and positively fatal result; yet it adds so 
much to the exhaustion, and is liable to be repeated, in some instances, at 
such short intervals that it results in bringing on complete collapse and 
death. The hemorrhages which occur in the first and second stages of tu- 
berculosis, when moderate in amount, not infrequently leave the patient 
feeling more comfortable and free from oppression than he was for several 
days before the hemorrhage occurred. But in the majority of instances 
hemorrhages, whether slight or more copious, not only greatly alarm the 
patient and the friends, creating a mental anxiety that of itself is depress- 
ing to the patient and calculated to hasten the further development of the 
disease, but they are usually followed b}^ some degree of increase of all 
the more important symptoms. Another symptom which needs perhaps 
an additional word of explanation is that of indigestion. A large pro- 
portion of tubercular patients complain but little of the digestive organs, 
but you will meet here and there one, who from an early stage of the dis- 
ease has suffered from loss of appetite, sense of heaviness in the epigas- 
trium followed by gaseous and sometimes acid eructations during the 
next two hours after taking food. 

The gastric symptoms often occasion more suffering to the patient and 
occupy more of his attention than any of the symptoms belonging to the 
pulmonary disease. This deprives the patient of good assimilation and 
nutrition and usually increases the rapidity of his failure in flesh and 
strength, and by exhausting the nutritive elements of the blood leads to 
an earlier supervention of the second and third stages of the pulmonary 
disease. Another symptom which rarely occurs in the early stage, but 
which is occasionally met with, is diarrhoea. From the beginning of the 
patient's failure in health before attention has been directed to the pul- 
monary disease by any marked symptoms, a chronic persistent form of 
diarrhoea, consisting of from one to five and six thin serous discharges 
from the bowels, usually accompanied by little or no pain, but only a 
sense of weakness or exhaustion, will come on insidiously without any 
apparent cause and sometimes without either impairment of the appetite 
or that part of digestion which takes place in the stomach itself. In many 



453 PHTHISIS. 

of these cases the diarrhoeal discharges are confined almost entirely to the 
morning, commencing; when the patient first rises from bed, and being re- 
peated from two to four times during the next two hours and then ceasing 
for the remainder of the day. In other cases the discharge will take 
place within from a quarter of an hour to an hour after each meal; the pres- 
ence of food in the stomach not occasioning pain or symptoms of indiges- 
tion, but simply exciting increased peristaltic motion of the bowels, until 
it ends in a discharge of thin fgeces, sometimes a second discharge follow- 
ing in a little time, and then the alimentary canal becomes quiet unt.l 
alter the next meal. Such patients seldom have more than a very slight 
tendency to cough, so slight and so little of associate symptoms referable 
to the chest, that the condition of the lungs is entirely overlooked and 
the whole difficulty is regarded as intestinal catarrh, in modern phraseol- 
ogy, or slight inflammation of the mucous membrane of the ileum, or per- 
haps some portion of the colon, but chieflv of the lower portion of the 
small intestine. Remedies that are given to overcome this condition al- 
ways temporarily relieve the patient, but the relief uniformly proves only 
temporary, and the difficulty speedily returns. 

In this way several months may be passed, the patient on the whole 
gradually losing flesh and strength, until he is unfit for work and obliged 
to keep his house. If at any time during the progress of the disease 
suspicion is aroused in regard to the lungs, and a closer examination is 
made by auscultation and percussion, the evidences of diffuse miliary 
tubercular deposit will almost always be recognizable in the upper part of 
one or both lungs. The true explanation of these cases is found in the 
deposit of the gray miliary tubercle in the follicles and glandular struct- 
ures of the mucous membrane of the ileum, simultaneously with their de- 
posit in the lungs. The deposits in the intestinal follicles soon cause a 
low grade of inflammatory action around them, causing the first appear- 
ance of the diarrhoeal discharges. This is soon followed by softening and 
disintegration of the tubercular granules and their disappearance in the 
evacuations, while numerous small but irregular ulcerations are left in 
their place. The progress of the disease in the intestines apparently di- 
verts more or less of the nervous sensibility from the pulmonary tissue, 
and lessens the active ordinary symptoms of local disease of the lungs. 
Yet in some cases while the ordinary symptoms of the progress of local dis- 
ease in the lungs are almost entirely absent, the deposit in the lungs un- 
dergoes its ordinary natural changes and will be found in an advanced 
stage of progress when the patient is apparently dying from the exhaust- 
ing influence of protracted diarrhoea and intestinal ulceration, as may be 
proved by the careful practice of auscultation and percussion. These in- 
testinal complications with tuberculosis need careful examination on ac- 
count of their liability to lead the practitioner astray in his early diagno- 
sis, and cause him to give assurances to his patient in regard to recovery 
that are delusive; and although it may not alter in any degree the prog- 
ress of the disease, yet such false assurances in regard to the nature of 
the case and the prospect of recovery, always shake the confidence of the 
patient and his friends in the competency of the physician, and not in- 
frequently cause his dismissal from further care of the patient. Conse- 
quently whenever chronic diarrhoea shows itself without an apparent 
cause, proves persistent and recurs after temporal relief from ordinary 
remedies, you should suspect some latent, unexplained disease, and give 
the patient a full examination, including especially physical exploration 
of the chest. This condition should lead you not only to make a direct 
physical exploration, but also a careful inquiry into the family history and 



ANATOMICAL CHANGES. 459 

tendencies as regards any hereditary influence in the direction of scrofula 
or tuberculosis. There are features of these cases, if they are examined 
into as carefully as possible, that will reveal to the practitioner such a his- 
tory and tendencies as will leave no doubt concerning the true nature of the 
case. The diarrhoea I have already mentioned is apt to supervene in the 
last stage of exhaustion, resulting from any form of chronic wasting dis- 
ease. 

Anatomical Changes. — The anatomical or structural changes which con- 
stitute the commencement of the early stage of tuberculosis, consist in 
the accumulation, in some portion of the pulmonary structure, of small 
aggregations or masses of organic matter which, when examined under 
the microscope, are found to be composed of imperfectly formed cells, gran- 
ules, nuclei, some amorphous hyaline matter, and inorganic material, 
chieliy compounds of lime, and more or less of fat granules. These 
constituents of the tubercle appear to be derived either from imperfect 
cell growth in processes of assimilation, or from the imperfect disintegration 
of cell structure in the natural processes of waste. Many of the earlier 
investigators regarded the tubercular masses as a result of previous inflam- 
matory engorgement and exudations. But there is not sufficient evidence 
that inflammatory processes have any necessary connection with the origin 
and deposit of tubercles. As I have shown when speaking of the consti- 
tutional conditions constituting the scrofulous and tuberculous diatheses, 
there is in almost, if not all cases, a stage of impairment in the properties 
or forces which govern the nolecular movements in the tissues, constitut- 
ing nutrition and disintegration, existing prior to the local develop- 
ment of the tubercular formations. And as these constitutional condi- 
tions are induced bv causes acting with feeble intensity through consider- 
able periods of time, and the local development of tubercle only super- 
venes after these general impairments have reached a considerable de- 
gree of development, I have every reason to suppose that they are sim- 
p'y the product, as before stated, of imperfect elaboration of material, and 
by its failure to be eliminated through the excretory organs, it assumes 
the form of genuine deposit in the structure. The precise location of the 
deposit varies. In some cases it appears in the interstitial spaces of the 
connective tissue, in other instances in the alveoli or air cells, and 'not in- 
frequently in both. In uncomplicated tuberculization, the morbid mate- 
rial commences as small granular masses, most frequently of a grayish 
color. These masses appear to increase in size by accretions to their 
growth, until when examined in an advanced stage of the disease, they 
may be found of all sizes, from a millet seed to that of a hickory nut. 

The changes which these masses undergo during the progress of the 
disease appear to be that of degeneration of the more elaborated portion 
of the material converting the imperfect cells and nuclei into a more 
yellow caseous substance, and still later into pus. These changes appear 
to progress faster in the center of the tubercular masses than toward their 
periphery; giving them, when laid open for examination, a yellowish, 
friable appearance, softer in the center than toward the circumference. 
As the lung tissue becomes congested and a low grade of inflammatory 
action is set up around the larger deposits, this apparent degeneration and 
softening goes on through the whole mass, until it becomes converted into 
a mixture of granular or cheesy material and pus. These ingredients of 
the softened tubercles may be often detected in the sputa of patients 
during the second stage of the disease. 

Several years since some of the European investigators, through experi- 
ments in inoculating tuberculous matter into small animals, as rabbits and 



460 PHTHISIS. 

guinea pigs, claimed to have demonstrated that the disease was ca- 
pable of transmission by inoculation. And, hence the conclusion 
was reached that tuberculosis was an infectious if not a directly 
contagious disease. More recently, however, it has been so clearly 
shown that inoculation of these animals with any other inflammatory 
product or even with organic matter derived from saliva, would 
result in similar deterioration of the animals and apparent tuber- 
cular deposit, that no reliance can be placed upon the deductions from 
these earlier experiments. Very recently Koch has discovered in the tu- 
bercular mass in the lungs and more readily also in the matter of expec- 
toration, an organic germ styled " bacillus tuberculosis," which he claims 
to be peculiar to this form of disease. He regards it as the essential 
cause of the disease. His observations have been confirmed by several 
other eminent microscopists, and have been either denied or modified by 
many others. That the bacilli or minute organisms may be found in the 
sputa there can be no doubt. The conclusion, however, that these minute 
organisms are the essential cause of tuberculosis, and that the tubercular 
deposits, with all the subsequent changes, start from inoculation of these 
bodies either inhaled through the lungs or in any other manner introduced 
into the system, has been altogether too hastily drawn. Before this con- 
clusion can be considered as established it must be demonstrated by a 
sufficient number of examinations, that these identical organic germs ex- 
ist in all tubercular deposits; not only in those that are undergoing soft- 
ening disintegration and from which matter of expectoration is furnished, 
but in the primary tubercular masses in the lungs, in the mesenteric 
glands, and in other lymphatic or adenoid structures in different parts of 
the body. Some examinations of the tubercular material in the mesen- 
teric glands have been very recently made without detecting these organ- 
isms. And it is more than probable, in my own estimation, that mature 
investigation in the early stage will lead to the final conclusion that the 
bacillus tuberculosis is only an accompaniment of the degenerative 
changes in the tubercular masses wherever found, thereby destroying the 
idea of their causative influence or of their playing a.i essential part in 
the propagation of the disease. 

Beside the formation of tubercular deposits and their transition 
from the imperfectly elaborated organic material of which they 
are composed into purulent material in the advanced stages of 
the disease, the pathological changes in the lung tissue, imme- 
diately surrounding the tubercular masses, is of much importance. 
These changes in the lung structure are strictly analogous to and prob- 
ably identical with a low grade of pneumonic inflammation. There is 
every appearance of a stage of engorgement in the vessels surrounding 
these masses. Engorgement is followed by exudation into the interstitial 
spaces of the tissue, causing increased density of the structure to such a 
degree as to incre sse the fremitus of voice and diminish the resonance on 
percussion, and to cause the greater part of the febrile phenomena 
accompanying the second stage of the disease. It is the accumulation 
of true inflammatory exudative products in different stages of progress 
that gives to the tuberculated portion of the lung its varying degrees of 
density, and not infrequently, on post mortem examinations, a close 
resemblance to the gray hepatization of the suppurative stage of un- 
complicated pneumonia. As the separate tubercular masses are in most 
cases very numerous, and as the changes they undergo usually take place 
in the order in which they were deposited, the earlier deposits generally 
mature and pass into the second stage or that of softening, while other 



DIAGNOSIS. 461 

deposits are just being formed; thus presenting in its progress a suc- 
cession of pathological changes, corresponding with the exacerbations and 
remissions that characterize the general symptoms and progress of most of 
the cases of tubercular phthisis. 

The same circumstances explain why, on post mortem examination, in 
laving open the tuberculated lung, you will often find all these changes 
present within the compass of a single lobe. And this explains why so 
often in the progress of this form of disease, the patient for a time pro- 
gresses unfavorably with steadily increasing emaciation, rapid pulse, co- 
pious expectoration, night sweats, and yet, after a time begins to im- 
prove; all the symptoms and the quantity of the expectoration gradually 
diminishing until he is flattered with the expectation of recovery, when 
without any real or apparent cause he begins again to have some increase 
of inflammatory or febrile symptoms, ending in a similar copious expecto- 
ration and a little further progress in emaciation and loss of strength than 
before. They thus undergo a succession of exacerbations lasting two, 
three or four weeks with intervals of moderate improvement perhaps of 
a similar length of time, which improvement raises new hopes and causes 
the patient and his friends to insist that they are recovering, only, however, 
to be disappointed with the development of suppurative action in the 
next series of deposits. 



LECTUEE XLVII 



Phthisis Pulmonalis Continued— Its Diagnosis, Prognosis and Treatment. 

GENTLE MEX: In regard to the diagnosis of genuine tubercular phthis- 
is little more need be said than to recall your attention to the physical 
signs I have already mentioned when describing the progress of the dis- 
ease, and their comparison with the presence or absence of physical signs 
in the diseases with which tuberculosis is most apt to be confounded. 
Indeed, there is but one form of disease that presents any apparent diffi- 
culties in its differentiation from the earlier stage of the tubercular deposit 
and that is bronchitis. The clinical history of bronchitis and the devel- 
opment of tubercular phthisis, are sufficiently distinct in their general 
features, when carefully examined, to enable the practitioner reliably to 
separate the one from the other, but from many patients it is impossible 
to get an accurate history of their case, such as is needed to form reliable 
conclusions, consequently the physical signs derived from auscultation 
and percussion become not only important but necessary to enable us to 
distinguish tubercular deposits, especially when of very limited extent, 
from any form of bronchial disease. There is no form or stage of 
the latter, which will give rise to diminished resonance on percus- 
sion, increased fremitus of voice, and simple alterations of the natural 
respiratory murmur. If there is any exception to this rule, it is in 
those cases of chronic capillary bronchitis which have resulted in the oc- 
clusion or closing up of a sufficient number of the bronchioles, to allow 
such a degree of collapse of the alveoli as to contract the chest and alter 



462 PHTHISIS. 

its resonance from the diminished capacity for air in consequence of such 
contraction. This stage of bronchitis, however, is preceded by a his- 
tory so characteristic of the disease, and the contractions so generally af- 
fect the middle and lower parts of the chest, as much or more than the 
upper, and are therefore so different from the flattening of the infia-elavicu- 
lar region of the chest antero-posteriorly at its apex or upper part, that the 
one can hardly be confounded with the other. Consequently, you are 
safe in deciding that there are deposits of some kind in the lung tissue 
and probably of a tuberculous character whenever accurate percussion in 
the infra-clavicular region elicits less than the normal resonance, and the 
voice gives increased fremitus or vibration through the walls of the chest, 
and the respiratory murmur is altered either by irregularity of develop- 
ment, prolongation, renewal in expiration or deficiency. If to these phys- 
ical signs, is added distinct flattening as determined either by measure- 
ment or inspection, you have all the evidences that are neede I to show, 
rut only that there is increased densit}" of the lung from some cause, but 
that such density is the product of tubercular accumulations. 

For while exudations from pneumonic inflammation may give rise to 
increased dullness on percussion and fremitus of voice, they are necessa- 
rily accompanied by the other phenomena of pneumonic disease, such as 
the characteristic expectoration, the phenomena of a general fever and are 
preceded by a history that dates comparatively but a few days back, 
for its beginning. Pulmonary oedema may also give rise to diminished 
resonance and increased fremitus of voice, but such oedema wiil not cause 
shrinking of the chest, and can result only from some prior disease, such as 
organic or structural lesions of the heart, structural diseases of the kidney, 
or other conditions tending to produce general dropsy. An exception 
may be met with in some instances of capillary bronchitis in children and 
in old persons in which the extreme dyspnoea causes want of oxygenation 
and decarbonization of the blood, and by thus secondarily impairing the 
vaso-motor influence over the pulmonary vessels, a degree of cedematous 
infiltration may take place in the pulmonary tissue, thereby inducing the 
physical signs I have named without the existence of any tubercular de- 
posits. But here also there is a preceding history of capillary bronchitis, 
or of general dropsy from either renal or cardiac disease, which differs 
very much from that of any stage of tuberculosis. 

Pleuritic effusion sufficient to compress the lung may cause increased dull- 
ness on percussion and alter the fremitus or vibration of voice, but it will 
neither cause flattening of the infra-clavicular spaces nor diminution of 
the chest artero-posteriorly, but will cause greater changes in the middle, 
lower and lateral parts of the chest, and will be preceded by such a 
clinical history as points distinctly to pleuritic inflammation and its con- 
sequences instead of tuberculosis. Therefore, if you are careful to first 
ascertain clearly the results of physical exploration by inspection, aus- 
cultation, and percussion, and before drawing your final conclusion, 
compare these results with a careful study of the preceding history of 
each patient with the present general symptoms, you can hardly fail to 
distinguish even the earliest stage of tubercular deposits from any of the 
other pathological conditions with which it is liable to be confounded. 
I call your attention to the diagnosis of this stage more particularly, be- 
cause of its great importance: it being the stage in which, with proper 
management, there is a reasonable chance for the patient's recovery. In 
the subsequent stages of tuberculosis, the diagnosis is still more easily 
made. With the increased accumulation of deposits, increased contrac- 
tion of the upper part of the chest, m re or less condensation of the lung 



DIAGNOSIS. 463 

t'ssue surrounding the tubercular masses, the dullness on percussion and 
increased vibration of voice become still more plain and easily recog- 
nized: and with the beginning of softening, come always more or less of 
sub-mucous or mucous rale-, fixed in the tissue or only partially removable 
temporarily by coughing. The expectoration itself, now, if properly ex- 
amined, may aid in confirming the diagnosis. 

In many cases, when softening has made considerable progress, the 
microscope will reveal more or less of the broken cells, nuclei, and gran- 
ular material that constitute the tubercular mass. Not infrequently may 
be detected, also, with close scrutiny, the fragments of the connective 
tissue of the lung. These, with more or less of pus globules, may be 
regarded as additional evidence that the expectorated matter is derived 
from softening and disintegration of tubercle, and not from any suppu- 
rative condition of the bronchial membrane. How far the detection of 
the bacillus in such expectoration is to be regarded as surely and posi- 
tively distinctive of the expectoration from the tubercular mass remains 
yet to be determined. That it exists in a great number of the cases of 
this kind of expectoration there is no doubt; but the investigation must 
be carried to the extent of making similar microscopic examinations with 
the same degree of minuteness in the muco-purulent matter derived from 
the second and third stages of bronchial inflammation, and also the ex- 
pectoration that occurs in the second stage of pneumonia when diffuse 
suppuration exists, before any positive conclusions can be reached. 
There is nothing yet on record indicating that these investigations have 
been made, and before we can conclude that the bacillus of Koch is 
distinctive of expectoration from pulmonary tubercle, all these other 
forms of expectoration must be examined with the same care as though 
each came from a well-marked case of phthisis. In the second stage of 
tuberculosis, as I have already stated, the diagnostic features are, the in- 
creased dullness on percussion, increased vibration of voice, more or less 
moist rales, varying much at different times according to the degree 
of softening and condensation of lung tissue, and the character 
and composition of the sputa. In the third stage of the disease, 
after suppuration in some portions of the lung has been completed 
and cavities have been formed, auscultation frequently reveals, not merely 
fremitus of voice, but that concentrated transmission of the voice directly 
to the ear or funnel of the stethoscope, which is called pectoriloquy; while 
percussion over most of the affected lung will still yield only marked 
dullness, yet whenever there is a cavity of considerable size near the sur- 
face of the lung, percussion may elicit a degree of tympanitic resonance 
over a very limited area, the surrounding parts being dull. Or, if a large 
cavity has a free communication with a bronchial tube, percussion over it 
will not unfrequently elicit that peculiar sound denominated " bruit clu 
pot fele," or cracked metal sound. It is thus, gentlemen, that by means 
of the faithful practice of auscultation, percussion, and the additional 
modes of physical examination, you may not only diagnosticate accurately 
tubercular disease in all its stages, but you may define accurately its ex- 
tent or degree of diffusion through the lung tissue, and very nearly the 
exact stage of advancement it has made up to that of extreme exhaustion 
of your patient and the approach of death. 

Prognosis. — In regard to prognosis much will depend upon the age of 
the patient and the circumstances which have led to the development of 
the disease. As a general rule, cases of a strictly hereditary character 
are less likely to be arrested in their course or be rendered abortive by 
any process of treatment than those which have originated de novo with 
the individual. And yet if the diagnosis has been made early, while the 



464 PHTHISIS. 

tubercular deposits are small and comparatively few in number, and the 
patient under thirty years of age, there is a possibility of arresting the 
further progress of tubercle formation and causing that which already 
exists to remain latent or sloVly diminish. That primary crude tu- 
bercular deposit is capable of undergoing arrest in its growth or in- 
crease, and of having its organic material slowly undergo disintegration 
and disappearance by absorption, leaving only a small speck of inorganic 
matter in the lung, we have abundant evidence furnished by postmortem 
examination after death from other diseases, in subjects who had at a 
previous period been known to be tuberculous. Not only may 
we make a favorable prognosis in many of the cases that come under 
observation in the early stage, but, in cases that are further advanced, 
even in the stage of softening or suppuration, if on careful examination 
the structural changes are found to be limited to the apex of one lung, 
and the patient capable of availing himself of the most favorable circum- 
stances for controlling the disease. Under such circumstances assur- 
ance may be given that there is a reasonable chance of recovery; not by 
arresting the progress of pathological changes in the affected part of the 
lung, but by sustaining the strength and nutrition of the patient until the 
disintegrated tubercular mass has disappeared by expectoration and the 
resulting cavity filled and cicatrized by the ordinary process of repair. 
This result may leave the upper part of that side of the chest more or 
less contracted and a moderate diminution of capacity for air as a perma- 
nent change, and yet the general health will be restored and may remain 
sufficiently good to admit of an active life during an indefinite period of 
time, or until destroyed by other forms of disease. But if the deposit oc- 
cupies more or less of both lungs, or if one lung has several places advanced 
to the second or softening and disintegrative stage, the chances of any 
permanent recovery are exceedingly small. Judicious management may 
greatly retard the progress of the disease under such circumstances, and 
render the patient more comfortable, but it is very rare that it will do 
more than this. As a large proportion of all the tubercular patients 
neglect to seek thorough examination and advice till the second stage has 
actually begun, so it is that almost all those that thus come under obser- 
vation force us to an unfavorable prognosis, which is only too surely 
verified by their ultimate failure and death from the subsequent progress 
of the disease. 

Treatment. — The management of the diathesis or constitutional condi- 
tion which exists prior to the deposit of tubercle in the lungs, at least in 
the large majority of cases, was considered sufficiently in detail, both in re- 
gard to hygienic measure and the administration of remedial agents in 
the lectures on the general pathology of the chronic constitutional dis- 
eases, and in that in reference to scrofula.* Consequently I shall here 
consider the treatment only as it relates to pulmonary tuberculosis after 
the commencement of the deposits. In the first stage of pulmonary tuber- 
culosis, there are three distinct indications to be fulfilled or objects to be ac- 
complished in its management; first, to so change the functions of nutrition 
and disintegration as to prevent the further development of the tubercu- 
lar material in the sj^stem; second, to render the deposits already existing 
abortive in their further progress; third, to correct such defects in the con- 
formation of the chest, or in the constitutional condition of the patient as 
may have supervened during this first stage. Keeping in mind the fact 
that tubercular material may be derived, either through defects in the 

* See Lectures XXVII and XXVIII. 



TREATMENT. 465 

processes of disintegration and elimination, or through imperfection in the 
processes of assimilation and the appropriation of new material to the 
tissues, it is evident that the management of cases belonging to the one 
class may require measures essentially different from those of the other. 
As explained when speaking of the etiology of the disease, those cases 
which originate from hereditary influences belong to the class in which the 
primary fault is in the assimilation of new material, while in a large propor- 
tion of the cases in which the diathesis has been acquired without hered- 
itary influence, it has resulted from exposure to such causes as interfere 
primarily with the oxygenation and decarbonization of the blood and sec- 
ondly with disintegration and excretion. 

To arrest the progress of further development of tubercle in the first 
stage, such measures should be instituted as are calculated especially to 
supply the patient with such a variety of food as will furnish all the mate- 
rial necessary for the nutrition of the various structures of the body; such 
an amount of pure, fresh air as will secure full oxygenation and decarbon- 
ization of the blood; and that degree of daily, habitual, muscular exercise, 
including especially the muscles of the chest, the trunk of the body and 
upper extremities, as is calculated to promote muscular nutrition and 
growth, and at the same time to increase the efficiency of the expansion of 
the chest. In many of these cases, if the circumstances of the patient 
will allow them, when properly directed, to secure all the influences neces- 
sary, including food, clothing, air and exercise, they may recover without 
a change of climate. But you will find a proportion of the cases, es- 
pecially patients between the ages of puberty and twenty-five years, 
whose growth has been unequal so that the chest is narrow in 
proportion to their height, lacking capacity for air, whose nutrition is 
defective as exhibited by a delicate, spare condition of all the tissues. 
In such, a judicious change of climate is almost an absolute necessity to 
secure success. The change needed for this particular class, is to an ele- 
vation, ranging between twenty-five hundred and five thousand feet, with 
a dry, mild condition of the atmosphere, if possible upon a dry soil with 
an acclivity to the south or east. Such an elevation of itself causes un- 
consciously increased frequency and force of respiration, to compensate for 
the increased rarity of the atmosphere. If the patient is kept much in 
the open air with moderate daily exercise, as should be the case, this un- 
conscious and continuous increase of the lespiratory movements leads to 
a steady increase in the expansion and capacity of the chest. And, if the 
patient is at the same time supplied with the necessary quantity and qual- 
ity of food, there is a reasonable certainty that a continuous residence in 
such a locality through a period of one, two or three years will secure a fair 
respiratory capacity, with a shrinking of the tubercular deposits already ex- 
isting or their conversion into small calcareous atoms thus rendering 
them abortive, and thereby accomplishing the second object of treatment 
at the same time with the first. 

In this class of cases, through the first stage of the disease, compara- 
tively little can be accomplished by the administration of medicines. I 
have thought in some instances during the early part of the treatment 
and especiably w T hen patients were not able to avail themselves of the ad- 
vantage of a change of climate, that the long continued use of such reme- 
dies as the lacto-phosphate of calcium in the form of syrup, or the syrup of 
iodide of calcium produced decided benefit. The addition of a table- 
spoonful of cod-liver oil twice a day, if these patients, on trial, find they 
can digest it without annoyance to the stomach, will increase the benefit, 
and add materially to the activity of nutrition and consequently aid in 
30 



466 PHTHISIS. 

arresting the further accumulation of tubercular material. The calcium 
compounds I regard as of more value than is generally supposed. Evi- 
dently, one of the defects in the nutrition favoring tubercular develop- 
ments is imperfect cell-growth. Long continued clinical observation has 
led me to the conclusion that the compounds of phosphorus and calcium 
in such forms as the lacto-phosphate of calcium, and iodide of calcium have 
a positive influence in promoting cell-growth and consequently of increas- 
ing the perfection of the nutritive processes. As a general rule almost 
any remedial agent or nutritive material that will increase the efficiency 
of nutrition will be beneficial to such patients. But it is not to their ad- 
vantage to be overdosed with medicines, more particularly with those 
that are calculated either to diminish the appetite for wholesome food, 
or the power to assimilate it. 

The class of tuberculous patients who come under our care in the first 
stage of the disease, in whom the tubercular diathesis has been created 
without hereditary influences, by living in damp, ill ventilated rooms, 
confined too closely to indoor occupations and all those modes of living 
by which the functions of disintegration and elimination are more or less 
impaired, are as much benefited by the same rule in regard to well regu- 
lated exercise in the open air, the selection of a diet containing the neces- 
sary variety and quality of material for healthy nutrition, and change of 
climate in the same direction, as the class of patients to which I have 
already referred. But, experience has shown that many of this class of 
cases, when they first come under observation, have special functional de- 
rangements of the digestive organs, such as defective secretion of gastric 
juice, an inactive condition of the bowels, not infrequently defective secre- 
tion of urine, a dry and unhealthy state of the cutaneous surface, and 
they will be greatly benefited by giving special attention to the removal 
of these various functional disturbances. It is true that good food, warm 
clothing and well regulated exercise in the open air will do much to cor- 
rect these, without medication. But it is equally true that the judicious 
administration of such remedies as will promote better secretion of gastric 
•juice, secure the daily evacuation of the bowels, and the taking after each 
meal of some of those agents that exert a general alterant and tonic influ- 
ence upon the system, will render the effects of good air and outdoor ex- 
ercise much more efficient in promoting the restoration of the patient. In 
this class of cases especially, the effect as a general alterant, and promoter 
of nutrition, of the syrup of the iodide of calcium in doses of four cubic 
centimeters (fl. 3j) after each meal will do much good. If the patient al- 
ready has some cough and morbid sensitiveness to atmospheric changes, 
the addition to each dose of the iodide of calcium of two cubic centimeters 
(fl. 3ss) of the fluid extract of humulus lupulus will render it more quiet- 
ing and increase its tonic properties. In those cases where the digestive 
organs are impaired causing more or less distress, flatulency and gaseous 
or acid eructations after each meal, I have found the use of a prescription 
containing carbolic acid* given in doses of four cubic centimeters (fl. 3j) 
just before each meal, to afford much relief from the gastric symptoms, 
while the intestinal discharges may be kept regular and natural by taking 
at bedtime a tonic and laxative pill composed of six centigrams (gr. i) 
each, of the extract of hyosciamus, sulphate of iron and aloes, and two 
centigrams (gr. -J) each of blue mass and extract of nux vomica. 

For restoring the skin to a healthier condition and securing more per- 
fect elimination of waste material, a warm bath rendered a little stimulat- 
ing by the addition of common salt may be taken twice per week, and after 

* See formula on page 138 of this vol. j 



TREATMENT. 4G7 

each bath as soon as the water is removed from the skin the whole cuta- 
neous surface should be rapidly and freely rubbed with dry, soft flannel un- 
til a comfortable glow of warmth is felt over all the surface. The class of 
patients of which I am now speaking are more liable, during this first 
stage of the disease, to have the tubercular deposits accumulate rapidly 
and in larger masses than those of hereditary origin, and correspondingly 
more liable to hemorrhages. Some of these cases, when sent to the moun- 
tain districts for better climate, and especially to the higher altitudes, be- 
come more liable to hemorrhage, experience more difficulty of breathing, 
and are soon obliged to return. The same parties going to a mild cli- 
mate, at a lower altitude, such as is found in the interior of Florida, some 
places at the ends of the Allegheny and Cumberland mountains in 
Georgia and Alabama, or still better in the Bermuda Islands, experience 
a high degree of relief, and make, apparently, rapid progress toward re- 
covery. Observation has also shown that some rare cases of tuber- 
culosis, in the early stage, are much more inclined to increase with 
frequent exacerbations of cough and of soreness in the chest, in the early 
part of autumn and in the spring months, and are better during the steady 
cold part of the winter season than during the heat of summer. I have 
seen some whose attack of hemorrhage occurred invariably during the 
warmer months of the year. 

I think such have almost always been most benefited by going to an el- 
evation of three or four thousand feet, and within the boundaries of Col- 
orado, Dakota or the northern portions of California and Oregon. Such 
of them as have resorted to the south, to Florida or to portions of the Gulf 
States, and in some instances to the Bermuda or the West India Islands, 
have been attacked with more frequent hemorrhages, and an increase in 
all the symptoms of their disease. I have known a few such instances 
of hemorrhagic tendency to be arrested and held at bay for years by re- 
sorting to the cold dry air of Minnesota and the region of Lake Superior. 
But another class of our patients manifest directly opposite tendencies. 
During the warm months of summer up to the commencement of the cold 
wet weather of autumn, they experience little inconvenience, and show 
but little outward signs of the existence of pulmonary disease; but always 
manifest indications of increased sensitiveness of the air passages and lungs 
and of more frequent spitting of blood, during the cold season. These, so 
far as I have had opportunity for observation and trial, have uniformly 
been benefited by resorting to the south, either to the hilly districts of 
Western Texas, as represented by San Antonio, the region of the gulf to 
which I have already alluded, particularly the orange grove regions of the 
interior of Florida or the Bermuda Islands. It is this class of patients 
also, that are found to be greatly benefited by sea vovages; more partic- 
ularly long sea voyages, taking them through a variety of climate upon 
the ocean, but usually avoiding the higher latitudes and colder parts of 
the ocean climate. 

In speaking of the benefits of change of climate during the 
first stage of tuberculosis, I must insist especially upon the bene- 
fits of changes which are either permanent or of protracted duration. 
The very common custom of making visits to the milder climates during 
two or three of the worst months of the year, and returning to the same 
influences under which the disease was originated the rest of the year, 
while productive of some benefit by retarding the progress of the disease 
and prolonging life, very rarely is efficient in actually arresting the devel- 
opment of tubercle or rendering that already developed abortive. You 
will perceive, gentlemen, by these remarks in relation to the adaptation 
Of climates to particular classes of tubercular patients, that much discrimi- 



468 PHTHISIS. 

nation and good judgment must be exercised if we would give to this large 
class of patients the degree of benefit to which they are entitled. It is not 
enough that the physician should by careful physical exploration ascertain 
the existence of the early stage of tuberculosis and simply tell his patient 
to go to a mild and dry climate, but it is equally incumbent upon him to 
inquire carefully into his patient's previous history, training and habits, 
and into the particular circumstances under which his symptoms became 
aggravated, and the relative influence of cold and warmth at different 
seasons of the year, that he may select, intelligently, the kind of climate 
as to altitude,, temperature, dryness, as well as the degree of exercise and 
outdoor exposure which is best adapted for benetiting each individual 
case. I am satisfied, from long observation, that the lack of discrimina- 
tion in these respects, together with the neglect to enjoin a sufficient de- 
gree of permanency in the changes made, has rendered almost nugatory 
a large part of the efforts made by consumptive invalids for the recovery 
of their health. 

The indications for treatment in the second stage of tubercu- 
losis, when the patient begins to have plain indications of softening 
in the tubercular masses and those inflammatory engorgements or low 
grades of circumscribed pneumonic attacks in the lung tissue contiguous 
to the tubercular mass, which usually constitute the first symptoms that 
aw^aken the patient and his friends to the necessity for seeking profes- 
sional advice, are, as far as practicable, the continuance of all those 
measures calculated to sustain and improve the processes of assimilation 
and nutrition, and in addition the prompt and judicious counteraction of 
those inflammatory congestions and exudations in the tuberculated por- 
tions of the lung which so frequently recur during this stage of the dis- 
ease. It is in reference to the warding off of these inflammatory attacks, 
and keeping the lung tissue as long as possible free from inflammatory 
exudation and suppuration that the treatment at present most in vogue 
for consumptive patients is defective. 

Regarding the disease as one of general impairment and the great ob- 
ject to be accomplished, that of improving and sustaining nutrition, the 
profession has recommended too indiscriminately the use of rich food, 
alcoholic drinks, and active exercise, without due regard to the existence 
of those frequent intercurrent attacks of genuine inflammation in the 
pulmonary tissue containing the tubercular deposits. The physician in 
this second stage should be constantly on the alert for these attacks, and 
promptly direct remedies for allaying the morbid excitability of the irri- 
tated pulmonary tissue and lessening the vascular congestion, thereby 
mitigating the cough, soreness, feverishness, and postponing, if not 
preventing the establishment of the suppurative process, and all its de- 
structive consequences. It is often as necessary, on a fresh exacerbation 
of feverishness, soreness in the chest, increased cough, and quick pulse, 
that the patients be placed at rest, in pure air, and limited to a well 
selected diet, and given mild anodyne expectorants with emollient ap- 
plications to the sore part of the chest, until these symptoms disappear or 
are much relieved, as it would be in similar attacks without any tubercular 
complications. But this fact is often overlooked, and patients encouraged 
to ride, walk and exercise every day, when a week or two of rest with 
proper treatment would effectually remove these symptoms and place the 
patients in a condition, where the cautious resumption of daily exercise, 
gradually increased, and a return to all those remedies and influences 
which tend to strengthen and improve the nutritive processes and the 
efficiency of the respiratory function would be well borne and highly 
beneficial. 



TREATMENT. 4G9 

I have soon oases not infrequently where the patients were suffering with 
all the complex indications of inflammatory action in the connective tis- 
sue around the tubercular masses, who had been ordered directly to 
change climate, take free outdoor exercise and a liberal diet. Some of 
those cases resulted in a general pneumonic attack, diffuse suppuration 
and death of the patients, while the condition of others was simply made 
worse. The remedies which I have found most efficient in warding off 
these inflammatory attacks, lessening cough, rendering the expectoration 
easy, promoting rest at night, and yet producing very little impairment of 
appetite or digestion, has been a combination of muriate of ammonia, tar- 
trate of antimonium and potassium, and sulphate of morphia, dissolved in 
the syrup of iiquorice in such proportions that four cubic centimeters or one 
teaspoonful would contain four decigrams (gr. vi) of the first, four milli- 
grams (gr. 1-16) of the second, and five milligrams (gr. 1-12) of the third. 
This quantity may be given every four, six or eight hours according to 
the severity of the symptoms. As soon as the more active inflammatory 
svmptoms have abated and this mixture is required only morning and 
evening, such patients may profitably commence taking almost any of 
those agents that promote nutrition, such as the compound syrup of the 
hypophosphites with cod-liver oil, syrup of the iodide of calcium, lactophos- 
phate of calcium, and in some instances the syrup of the iodide of iron. 
Quinine also is frequently given with benefit in doses of thirteen to twenty 
centigrams (gr. ii to iii) three times a day. 

In cases liable to hemorrhages, either with or without febrile exacer- 
bations and inflammatory symptoms, ergot or preferably ergotin, becomes 
one of our best remedies. During the hemorrhage the ergotin may be 
given in doses of from thirteen to twenty centigrams (gr. ii to iii) every 
two or three hours, according to the activity of the hemorrhage. After 
the blood has ceased, the patient will be benefited, and a recurrence 
of hemorrhage prevented by continuing thirteen centigram doses of the 
ergotin three times a day, for one, two or even three weeks. And if night 
sweats have supervened, as occasionally happens in the last half of the 
night, two decigrams (gr. iii) of the ergotin, taken between eight and 
nine o'clock in the evening, will be one of the best remedies for arresting 
these sweats. During the second stage of tuberculosis, the question of 
change of climate and the degree of outdoor exercise that the patient shall 
take must depend much upon the extent of the tubercular deposit and 
the degree to which the lung tissue has become involved in morbid 
changes. 

A large proportion of the cases in this stage will be temporarily bene- 
fited by going, during the cold and transition periods of the year, to a 
mild and dry climate, with only a moderate elevation. The higher eleva- 
tions of five, six or even four thousand five hundred feet should be 
avoided. If they are ever reached it should be done gradually at succes- 
sive stages from the lower to the higher elevations alluded to. But if the 
patient finds a climate in which the progress of tubercular changes is ar- 
rested, and reparative processes are so far established as to indicate re- 
covery for the time being, he should be induced, if practicable, to make 
that climate his permanent home. For experience has abundantly shown 
that these temporary appearances of returning health are often delusive; 
and if the patient returns to the same climate in which his disease origi- 
nated, characterized by cold, damp, and frequent changes, as in the north- 
ern belt of this country, he will rarely pass through the first cold season 
without having all the phenomena of his disease renewed in an active 
form. When the disease has passed beyond this second stage, and the 



470 PHTHISIS. 

suppurative processes have completed excavations of more or less size in 
the structure of the lungs, with many additional places not excavated but 
in a softened and purulent condition, with much emaciation, it is very 
rare that any change of climate proves either beneficial or desirable. And, 
at such a period in the advancement of the disease, to induce the patient 
to tax his weary limbs and emaciated form with the effort to find a better 
climate, and perhaps die among strangers, is a cruelty instead of an appro- 
priate remedy. The only cases in the third stage of advancement that offer 
a hope of recovery from any such change are those rare instances in which 
the deposits have been limited to the upper portion or apex of a single 
lung. In such, although the part affected may have passed through the 
three successive changes and left a well marked excavation furnishing 
purulent sputa and moderate hectic symptoms, yet the patient still has 
one whole lung and the greater part of the other left intact, which should 
be sufficient for carrying on the respiratory function efficiently until the 
reparative processes have restored the diseased parts by granulation and 
ultimate cicatrization, and brought the patient to recovery. I have seen 
some instances in which this result was obtained without a change of cli- 
mate. A judicious and favorable change, however, will facilitate it and 
render its accomplishment more certain. But where, as in the great mass 
of cases, the suppurative process has involved a considerable portion of 
one or of both lungs, there is no rational hope of the patient's living 
till repair can take place. Consequently, both the interests of the patient 
and his friends, as well as the common principles of humanity, require 
that such parties be candidly informed of the condition and prospects of 
the patient. At the same time give them the comfort that can be ob- 
tained by quiet, rest, a home among their friends, as good air as can be ob- 
tained, careful selection of nourishment and repression of the more troub- 
lesome symptoms by appropriate remedies and you will do as much to 
alleviate the suffering and protract the life of your patient as the nat- 
ure of such cases will permit. 

The same combination of anodynes and expectorants as were men- 
tioned in the second stage may still be taken at night, to lessen cough 
and promote rest. The use of such tonics as syrup of the iodide of iron, 
sometimes combined with glycerine, given in appropriate doses, largely 
diluted with water, will materially lessen the suppurative process, and the 
use of ergotin in sufficient doses, once or twice in twenty- four hours, will 
greatly lessen the night sweats. The particular remedies to be used, 
however, must be selected by the good judgment of the practitioner, ac- 
cording to the indications in each individual case. I have thus described 
the treatment in the different stages of tubercular disease in the lungs 
with a view of giving you the principles on which the treatment should 
be based, and remedies should be selected, whether hygienic, climatic, 
or medicinal rather than to multiply suggestions of individual remedies. 
I am fully satisfied that there are large numbers of cases of tubercular 
disease of the lungs which if diagnosticated and treated on the principles 
that I have indicated in the early stage would be rendered abortive, the 
health preserved, and a few would be snatched from the further progress 
in the second stage of the disease. And yet, with all our care, and the most 
intelligently directed efforts to give this class of patients all the chances 
that the present status of medicine and hygiene will afford, a very large 
majority will progress to a fatal result. And pulmonary tuberculosis will 
probably continue for ages to come, as it has been during the ages past, one 
of the most direful diseases known to the human race: destroying more 
lives by far annually among the civilized portions of the human race than 
any one of all the dreaded epidemics and scourges that can be named. 



PERICARDITIS. 471 



LECTUEE XLVIII. 



Inflammations of the Central Organs of Circulation — The ifferent structures involved — 
Pericarditis— Its Causes, Symptoms, Anatomical Changes, Diagnosis, Prognosis and Treatment. 

GENTLEMEN: I now invite your attention to the inflammations affect- 
ing the vascular system or organs of circulation. These organs include 
the pericardium and the heart as the center of the system, and the arteries 
and veins, capillaries and lymphatics. The diseases of the arteries, veins 
and lymphatics are so largely connected with injuries and affections of a 
surgical character, that the inflammations affecting them are fully treated of 
in works on surgery, and instruction concerning them is usually included 
in the courses on surgery in all the medical schools. I shall, therefore, 
pass them by with the exception of the aorta. This leaves for our consid- 
eration, chiefly, the central organs of the circulation composed of the peri- 
cardium, heart and the aorta. Inflammation maybe limited to the serous 
membrane called the pericardium, which surrounds the heart in the form of 
a sac and is reflected over its exterior surface. It is then called pericarditis. 
It may be limited to the muscular structure of the heart and is then called 
either carditis or myocarditis. It may be restricted to the interior cavi- 
ties of the heart, including the valves and columnae carnae, and is then 
called endocarditis. The two latter, myocarditis and endocarditis are 
so generally associated together in the same case, that for practical pur- 
poses they may be considered under the same head. You may have in- 
flammation affecting these various structures, occurring more or less at all 
periods of life, and in both sexes, but not as frequently as we have inflam- 
mation of the organs of respiration. For an idiopathic, primary inflam- 
mation of any of the cardiac structures occurring independently of other 
and more general diseases, is comparatively rare. You may also meet with 
cases of inflammation in these structures presenting all grades of activity, 
from the most acute and rapid in progress to the most chronic and pro- 
tracted in duration. 

Pericarditis. — I shall first direct your attention to inflammation of 
the serous membrane called pericardium. Acute pericarditis is of fre- 
quent occurrence in connection with acute rheumatism or rheumatic fe- 
ver, also as a complication of renal diseases, more particularly the different 
forms of albuminuria and structural diseases of the kidneys, and less fre- 
quently as a complication or as a sequel of eruptive fevers, more particularly 
scarlatina and diphtheria. According to the statistics of some recent writ- 
ers, one case out of every six of rheumatism of an acute character be- 
comes complicated with pericarditis. This, however, is a very much 
higher ratio than has occurred under my observation during a period of 
many years both in private practice and in the hospitals. In referring to 
some of the records I am quite sure that taking both classes of cases, 
those in private practice and in the hospitals, I have not met with pericarditis 
in connection with any grade of rheumatic disease in a larger proportion of 
cases than one in thirty. When it occurs in connection with rheumatism 
it is not in the form of metastasis or translation of the rheumatic inflam- 
mation from the fibrous structures or articulations to the pericardium, but 
is the result of the action of the same cause pervading the blood, that 
gives rise to inflammation in any other portion of the body, and its occur- 
rence in the pericardium in nowise lessens its coincident progress in ei- 



472 PEEICAKDITIS. 

thor the articulations or other structures. Its occurrence in connection with 
renal disease is traceable to the effects of retained urea or an excess of the 
constituents of urine in consequence of the inability of the kidneys to per- 
form their office. It is probable that it originates from a similar cause 
when it occurs coincidently with, or is a sequel of the eruptive fevers; it 
being most likely to occur where the function of the kidneys has been 
interfered with prior to the occurrence of the periodical disease. The oc- 
currence of acute pericarditis aside from its connection with the general 
diseases and pathological conditions already alluded to, and independent- 
ly of traumatic influences, such as wounds and injuries, is very rare. As a 
disease arising from atmospheric influences such as exposure to cold, sud- 
den changes, dampness, with which inflammations of the respiratory organs 
are so intimately connected, pericarditis is hardly known. I have met 
with two or three instances, occurring in patients who, after being subject- 
ed to severe and protracted muscular exercise, causing free perspiration, 
were suddenly exposed to sufficient cold, damp air to make a chilling im- 
pression upon the system. These attacks were undoubtedly the result of 
a sudden impression of cold and damp on a state of the system rendered 
more susceptible by the immediately preceding exercise. In a few in- 
stances I have met with pericarditis as a complication and coincident of 
pleuritis; not apparently caused by extension of the disease from the 
pleura to the pericardium, but both occurring from the same cause. 

St/mpto?ns. — In a large majority of cases of acute pericarditis the 
disease manifests itself abruptly, by initial "chilliness, coincident with 
pain, and a sense of oppression in the region of the heart. The chilliness 
is of very brief duration, sometimes hardly noticeable, and is followed by 
acute pain, resembling in all respects the pains described as characterizing 
acute pleurisy, only they originate more directly in the cardiac region, and 
often radiate backward under the left scapula, and sometimes upward to 
the top of the shoulder. The pain is not continuous, but rather paroxysmal, 
and is aggravated much by full inspirations or any other motions of the 
body or chest which may cause movements of the pericardium, in its re- 
lation to the parts around it. The acute pains in the pericardial region 
are accompanied from the beginning by increased frequency of pulse, 
short and hurried breathing, increase of temperature, constituting a mod- 
erate grade of general fever; more or less flushing of the face, a decidedly 
anxious expression of countenance, and a frequent, short, voluntarily sup- 
pressed cough with no expectoration. The secretions generally are 
diminished, the urine being more scanty and higher colored than natural. 
A thin whitish fur forms upon the tongue, and there is considerable thirst. 
In some cases there is severe frontal headache. In a few instances the 
pain in the head is accompanied b}* more or less tendency to delirium, the 
latter being sometimes sufficiently prominent to divert attention from the 
real seat of the disease in the pericardium. In its acute form, the course 
of the disease is usually rapid, the pulse becoming more frequent and less 
full, until it ranges from one hundred and twenty to one hundred and forty 
per minute, and is easily compressible. 

There is also a great sense of oppression or fullness in the cardiac 
region, increased by attempting to assume the recumbent position. Loss 
of flesh, paleness, and still more anxiety in the expression of the counte- 
nance, more frequent, short, dry cough, voluntarily suppressed as much 
as possible to avoid the pain that it occasions is also noticeable. ■ In cases 
of the greatest degree of intensity these symptoms increase rapidly, not in- 
frequently occasioning feelings of syncope, some degree of mental wander- 
ing, persistent disposition to keep the upright position of the body or to 



SYMPTOMS. 473 

loan a little forward. The heart's action is irregular and feeble. There is 
coldness of the extremities, blueness under the nailsand of the lips, short, 
panting respiration, great desire to sleep without the ability to do so, the 
patient generally starting up as if frightened, almost as soon as conscious- 
ness was lost in sleep. The patient now becomes extremely weary, pale, 
haggard, with sometimes a little puffiness or oedema of the eyelids, and if 
not relieved by treatment before the middle or latter part of the second 
week, the heart becomes so embarrassed from the exterior pressure of the 
pericardial effusion that it is no longer capable of maintaining the circu- 
lation, and the patient dies. 

When the disease occurs as an idiopathic affection without complication 
with renal or other prior diseases, it rarely presents as severe a course as 
I have just indicated. The symptoms, however, are the same, only less 
intense, and after about two weeks the patient begins gradually to im- 
prove, the fever abates, the pulse becomes a little slower and more 
steady, the sense of oppression in the chest less, and the improvement in 
these respects increases gradually from day to day until, during the fourth 
week, the patient reaches convalescence. In some cases there will be 
shortness of breath and inability to exercise for a longer period than 
this; often as long as from six to seven weeks from the commencement 
of the attack. This protraction of the case arises generally from the con- 
tinuance of irritative action and the slowness of absorption of the effused 
fluid in the pericardium. A great majority of cases run their course 
and have a tendency to terminate in recovery in from three to four weeks. 
A few may even terminate in convalescence in two weeks from the 
commencement of the attack. When the disease occurs as a complica- 
tion of rheumatism the symptoms are essentially the same as I have de- 
tailed, throughout its entire course, with the exception of the absence of 
initial chilliness and the modifications in the general grade of fever pro- 
duced by the accompanying general rheumatic affection. In the cases 
associated with rheumatism the tendency is generally to recovery, only a 
small proportion of the whole number of cases terminating fatally. 

When the disease originates from retained renal excretions or from 
retention of similar excretory matter in connection with the eruptive 
fevers, it is very much more likely to progress unfavorably and terminate 
in death. The latter class of cases usually occur in conditions of the sys- 
tem already anaemic and inclined to take on readily copious serous effu- 
sions. And in the cases of complication with renal disease the patient is 
not infrequently affected with general anasarca prior to the superven- 
tion of the pericardial inflammation. In consequence of this the latter 
affection is accompanied by early and unusually copious serous effusion, 
and is very liable to produce fatal compression of the heart before it can 
be controlled by remedies. Some of this class of cases may reach a fatal 
result w 7 ithin twenty-four, forty-eight or seventy-two hours from the time 
of the commencement of the attack. 

Thus far I have spoken only of the general symptoms and progress of 
the disease, which, though sufficiently characteristic to afford a pretty safe 
diagnosis, yet, they may be so closely simulated by pleuritic inflammation 
and perhaps some other affections that it is always desirable to note care- 
fully the signs to be obtained by auscultation and percussion. If these 
are noted, they are sufficiently characteristic to render the diagnosis easy 
and reliably certain. During the first stage of acute or subacute inflam- 
mation the pericardial membrane is simply intensely injected, tumefied 
and dryer than natural. The membrane covering the exterior of the 
heart and that lining the pericardial sac have their surfaces in contact, and 



474 PERICARDITIS. 

the motions of the heart rub these surfaces against each other, thereby 
producing in this first stage of the inflammatory process a rubbing or fric- 
tion sound precisely of the same nature as the friction sound that I have 
described when speaking of the first stage of acute pleuritis. It is generally 
heard as a double sound both in the systolic and diastolic movements of the 
heart, and while of the same character as the friction in pleuritis it is dis- 
tinguished from the latter by its occurring synchronous with the move- 
ments of the heart and not with those of respiration. This friction sound 
is usually heard most distinct and earliest over the central part of the car- 
diac region near the base of the heart. And in some cases it may continue 
to be heard in this region throughout the whole course of the disease. 
In the great majority of acute and subacute cases it ceases to be 
heard somewhere between the beginning of the second and the end. of 
the fourth day of the disease. When this disappears the cardiac sounds 
appear more distant and the impulse fails to be felt as plainly against the 
walls of the chest as in the natural condition or as existed at the commence- 
ment of the disease. 

This more distant beat of the heart and lessening of the impulse occur- 
ring at the same time with diminution or disappearance oi the friction 
sound would of itself suggest the occurrence of serous effusion sufficient 
t > separate the two surfaces of the pericardium and remove the heart a 
little farther from the walls of the chest. If we now practice percussion 
carefully we shall find that the area of cardiac dullness is decidedly in- 
creased, more particularly transversely on a line with the lower margin of 
the nipple, and to a very appreciable extent also vertically; even making 
the area or extent over which the cardiac dullness is well marked, from 
one third to double the natural size. At the same time in many cases 
there is a perceptibly increased fullness or bulging of the cardiac regidh 
particularly noticeable in the intercostal spaces in the center of the car- 
diac region. These physical signs taken in connection with the general 
symptoms and the location of the pains the patient suffers are sufficient 
to distinguish the disease from any other inflammatory condition within 
the chest. They are not only sufficient to distinguish it from inflammations 
of other structures, but they are sufficient also to indicate the stage of the 
disease, and the pathological changes which have taken place during its 
progress. 

Pathological Changes. — You will have noticed from the description I 
have given that pericarditis is divisible in its progress into the same num- 
ber of stages as pleuritis. The pathological changes are also identically 
the same: that is, we have first, intense injection or accumulation of blood 
in the vessels of the pericardium, giving it an intensely red and tumefied 
appearance during which we have friction sound. In from twenty-four 
to forty-eight hours, usually, this engorgement is followed by exu- 
dation. In the large majority of cases the exudation is of a mixed char- 
acter, partly plastic, forming a layer of organizable material on the surface 
of the inflamed membrane, and partly serous, which gives rise to a more 
or less rapid accumulation of a serous fluid in the pericardial sac. The 
relative proportion of these two kinds of exudation varies much in differ- 
ent cases. In a very few occurring in individuals whose blood is highly 
plastic the exudation is entirely of a plastic organizable character and 
rapidly solidifies into a thick layer of false membranous material which 
closely adheres to the inflamed surfaces, and soon forms a bond of union 
between them, causing adhesion of the exterior pericardial membrane to 
that covering the body of the heart. The motions of the heart frequently 
cause this layer of plastic material to be worked into little masses or tufts, 



ANATOMICAL CHANGES. 475 

that give to the surfaces the appearance of being covered with a ragged, 
fibrinous layer with tuft-like projections which had been united with the 
opposed surfaces. When the patient survives in this class of cases this 
plastic exudation forms a bond of permanent union between the two sur- 
faces of the pericardium. 

Occasionally this will be so complete that the pericardial sac is entirely 
obliterated. In other instances the adhesions will occupy only a part of 
the surfaces, leaving other portions free. At first the adhesions offer some 
embarrassment to the cardiac action and give rise in the feelings of the 
patient to more or less inconvenience and sense of oppression. This 
gradually disappears with time, and the modified friction sound that con- 
tinues throughout the whole course of the disease, and that may be pro- 
tracted even into the period of convalescence, eventually disappears. The 
adventitious tissue becomes smooth and attenuated to such a degree 
as to cause no longer any abnormal sound. In a larger number of cases 
the plastic exudation is sufficient only to form a layer of white fibrinous 
material unequally distributed over the inflamed surface, and to 
cause small patches of adhesion near the base of the heart, while the 
serous effusion accumulates with such rapidity as to separate all the free 
surfaces of the pericardium from each other, and to give rise sometimes to 
a degree of distension of the sac and consequent pressure upon the body 
of the heart, so as to embarrass its action. It is this accumulation of 
serous fluid in the pericardial sac that in severe cases causes the extreme 
sense of fullness, difficulty in lying down, and irregularity and weakness 
of the heart, to so great a degree as to occasion a fatal result. More 
generally the pericardial effusion is only sufficient to produce moderate 
distension. 

% The fluid in some cases is clear, and in others slightly turbid. In the 
latter case it contains some white corpuscles and pus globules, and in 
rare instances, enough of the red corpuscles of the blood to give it a 
tinge of redness. Suppuration, however, in the pericardium is very much 
more rare than in the pleura. Still it occasionally occurs, more especially 
when the inflammation has supervened upon some previous impairment 
of the constitutional condition of the patient. The structural changes 
in the inflamed membrane itself are simply those which are observed in 
all inflammations of structures made up largely of connective tissue. 
They consist in an increase of the endothelial cells and hypertrophy of 
the connective tissue itself. If you follow those cases of pericarditis 
that result in extensive adhesion of the pericardial sac to the body of 
the heart, to their remote consequences, you will find that they generally 
lead very slowly but surely to an increased growth or hypertrophy of the 
muscular structure of the heart; so gradually, indeed, that it requires 
many years in some cases, before this hypertrophy produces sufficient 
inconvenience to attract serious attention. In a few instances, however, 
the progress of this change is more rapid, and in addition to a simple in- 
creased muscular growth, you find more or less dilatation of the cavities 
of the heart, making the increased size consist partly of dilatation and 
partly of muscular hypertrophy. 

A case illustrating the slowness of these changes occurred under my 
observation a few years since, in which I had the opportunity of witnessing 
the post mortem examination of the patient who had died with general 
dropsy, which was preceded one or two years by constant and very dis- 
tressing irregularity and inefficiency of cardiac action, rendering him wholly 
incapable of active exercise; yet previous to these last two years he had 
led an active business life, being very rarely confined to his house by sick- 



47G PERICARDITIS. 

ness, making no complaint, and passing, as a good and sound subject several 
times, examinations for life insurance. As his family physician I had ex- 
amined him several times in the course of the twelve years prior to the last 
two without detecting any other fault in the heart's action than unusual 
slowness of beat and an occasional intermittence. I first detected the slow- 
ness and intermittence of his pulse on his recovery from an attack of epi- 
demic cholera in 1854. And yet on the post mortem examination the peri- 
cardium was found so closely adherent to the entire surface of the body of 
the heart as to leave not one square inch of that surface free, and so close as 
to require actual dissection with the scalpel to separate one layer of peri- 
cardium from the other. Nearly the. entire circumference of the pericar- 
dium, also, contained thin laminae of bone, in some places a line in 
thickness, and the different plates so closely touching each other a to 
form an almost continuous bony case around the heart. Piates of bone 
were also found in a few of the arteries; quite large ones in the aorta, and 
in various places where examination was made even as remote as the femoral 
artery in the middle section of the thigh. The muscular structure of the 
left ventricle was one third thicker than natural; both ventricles were di- 
lated to a larger size than natural, making the whole heart nearly twice 
its normal size. In closely examining the previous history of the patient 
it was found that these pericardial adhesions had resulted from an attack 
of acute pericarditis more than thirty years previously. 

Diagnosis. — In describing the symptoms and physical signs, I have al- 
ready indicated those which are specially diagnostic of this form of dis- 
ease. The only cases in which they are liable to fail in constituting a safe 
guide, are those rare cases of pleuritis in which the iatter inflammation 
occurs in that part of the left pleura in contact with the pericardium. 
A few of these cases have been found to yield a friction sound synchro- 
nous with the motions of the heart, although the pericardium was itself 
free from inflammation. The systolic action of the heart produced suffi- 
cient motion in the adjacent pleura to occasion a friction. These cases can 
usually, however, be separated from the friction of true pericarditis by 
noting carefully two things: first, that although the motions of the heart 
produce a rubbing or friction, the respiratory movements also produce a 
friction. After carefully watching these respective movements and espe- 
cially having the patient suspend respiration for a few seconds so as to get 
the movements of the heart separately, then resume respiration, usually it 
can be ascertained that the friction sound exists with the respiratory 
movements as well as with the cardiac. The other circumstances which 
aid in the diagnosis are that this friction, when dependent upon pleuritis, 
is always on the left margin of the cardiac space, and is also audible with 
the respiratory movement alone still further to the left, showing that it fol- 
lows the position of the pleura and not of the pericardium. 

Prognosis. — You will infer from what has already been said that acute 
pericarditis, when not associated with renal disease or with eruptive fe- 
vers, has a general tendency to recoverj-, and that the ratio of deaths di- 
rectly from the disease in small. This remark is applicable not only to 
strictly idiopathic pericarditis, but also to those cases of the disease 
which arise in connection with acute rheumatism. On the other hand a 
very large proportion of the cases that occur as complications in the prog- 
ress of acute and chronic renal diseases, and as the sequel of eruptive 
fevers, prove fatal. 

Treatment. — As the pericardium possesses similar anatomical structure 
and similar functional relations with the pleura, and as the inflammations 
affecting it pursue the same general course, pass through the same stages, 



TREATMENT. 477 

and produce the same anatomical changes as in inflammations of the 
oleura, so the indications for treatment are in all respects similar. Hav- 
ing fully discussed the subject of treatment of pleuritis, only 
a few days since, I do not deem it necessary to enter into the same 
detail in reference to the disease now under consideration. The princi- 
ples which govern us in the management of acute pericarditis being 
identical with those set forth for pleuritis in the several stages, 
and the remedies for accomplishing the objects being also the same, it is 
sufficient to refer vou to the treatment of the latter disease as applicable 
to the former. This remark applies strictly to the use of such remedies as 
bleeding, general and local and cardiac sedatives in the first stage of acute 
eases, and the subsequent use of remedies to promote absorption of the 
effused fluid, and diminish the plasticity of the organizable exudation as 
alteratives, diuretics, and counter-irritants. 

I must make an exception, however, in reference to those cases which 
occur in the progress of acute articular rheumatism. In these, in ad- 
dition to such treatment as I have recommended in the different stages 
of pleuritis, it is of much importance that the patients have early and 
efficient treatment with alkaline carbonates, more especially the carbonates 
a d bicarbonates of sodium and potassium, sufficient to fully neutralize the 
supposed acid cause of the rheumatic inflammation. And, it is proper to 
add, that as the exudations in the earlier stage of acute rheumatic inflam- 
mation are pre-eminently plastic and disposed to take on permanent 
organization, the use of mercurial alteratives as an item in the treatment 
during the first two or three days of acute pericardial inflammation may 
be productive of decidedly good effects; being careful always not to 
continue their use until the establishment of salivation or any unpleasant 
symptoms affect the mouth. Those cases of pericarditis which are asso- 
ciated with renal disease, or occur as the sequel of eruptive fevers, are asso- 
ciated with a debilitated and generally anremic condition of the blood, and 
consequently they will not bear active depletion, either by loss of 
blood or the use of such evacuants as are calculated to further deplete 
the patient. In such cases the chief reliance must be placed upon the 
use of such anodynes and diuretics as will lessen the pain, keep up as 
efficient action of the kidneys as possible, and upon the cautious use of 
remedies to lessen the frequency without impairing the force of the heart's 
action. 

Of the e, the fluid extracts of the cactus grandiflora, convallaria, and 
digitalis are the best. To these may be added blisters or some form of effi- 
cient counter-irritation. When the pericardial inflammation has assumed 
a chronic form, as it sometimes does, either primarily or as the sequel of 
an acute attack, there is usually a tendency to continue the serous exuda- 
tion causing a progressively increased distension of the pericardial sac 
and pressure upon the body of the heart. In all such cases, whether they 
are idiopathic, or whether they arise as complications of other diseases, the 
use of iodine alteratives internally, aided by digitalis and persistent 
counter-irritation by a succession of small blisters, will constitute the best 
mode of treatment, and will in many cases check the further progress of 
the disease and lead to the ultimate re-absorption of the effused fluid, 
and the recovery of the patient. But, where this treatment fails and the 
pressure begins to assume a dangerous degree of influence over the heart's 
action, threatening the life of the patient, no further time should be lost 
without resorting to the puncture of the pericardium and the evacuation 
of the effused fluid. In cases requiring such puncture, usually the disten- 
sion of the pericardium is such as to have increased its transverse diame- 



478 ENDOCARDITIS. 

ter more than one half, and usually the most favorable place for the punc- 
ture either for aspiration or any other method, is in the fifth intercostal 
space, perhaps an inch or an inch and a half to the left of the margin of 
the sternum. This may be varied in particular cases, and the practitioner 
should judge in each case by a careful examination and percussion as to 
the exact outline of the pericardial distension, both transversely and ver- 
tically, and aim to make his puncture over the most prominent and fully 
distended part of the pericardial sac. In the large majority of 
cases it will be found at the point I have indicated. The op- 
eration of tapping the pericardium has been performed a suffi- 
cient number of times to show that it is not only justifiable, but, with 
a sufficient proportion of recoveries from cases that would otherwise have 
proved fatal, to make it the duty of the practitioner to give his patient 
this additional chance of recovery. Instead of using the aspirator nee- 
dle and removing the fluid by the ordinary process of aspiration, it is bet- 
ter to puncture the pericardium with a trochar to which is fitted a David- 
son's syringe, for the reason that the stylet of the trochar being with- 
drawn leaves no sharp point to wound the surface of the heart as the fluid 
is drawn off and the distension of the sac diminishes. In those cases of 
pericarditis which occasionally occur, terminating in suppuration and pre- 
senting a fluid when withdrawn, either wholly or partially of a purulent 
character, the prognosis is very much more unfavorable; and yet, there 
are on record several cases of this kind that ultimately recovered. There is 
no absolute barrier against their being treated in the same manner as 
cases of empyema resulting from suppurative pleuritis; that is, by free 
opening and drainage. 



LECTURE XLIX. 



Myo- and Endocarditis ; Their Relations, Causes, Symptoms, Anatomical Changes, Diagnosis, Prog- 
nosis and Treatment. 

GENTLEMEN: As we stated at the commencement of the preceding 
lecture, myocarditis means inflammation limited to the muscular struct- 
ure of the heart. In a large proportion of the cases, more especially of 
rheumatic inflammation of the heart, the disease has commenced in the 
muscular structure alone. I have been able to detect in many cases 
from one to three days before the development of any of the physical 
signs of inflammation in the endocardium, that quick, irritable and excit- 
able systolic action of the heart, accompanied by a lengthening or ex- 
aggeration of the first or systolic sound, and a dull heavy pain in 
the cardiac region which indicated positive irritation in the muscular 
structure. And in a very few instances the pain accompanied by the 
physical signs I has described, after continuing from three to five days, 
under efficient treatment has disappeared without the supervention of any 
further cardiac symptoms. I have regarded these as cases of true myocar- 
ditis of a mild character, progressing no further than to involve the muscular 
structure, while the former cases represented the commencement of the dis- 



SYMPTOMS. 479 

ease in the muscular structure first, and extending directly to the endocar- 
dial membrane, and finally developing all the phenomena of endocarditis. 
Endocardial inflammation is of frequent occurrence as an accompaniment 
of inflammatory rheumatism, but as a separate disease, arising from the 
ordinary causes of inflammation in other structures of the body, it is com- 
paratively infrequent. Neither does it occur as often as pericarditis in 
connection with either renal disease, or the idiopathic or eruptive fevers. 

Symptoms. — The symptoms which characterize acute endocarditis, 
whether occurring in connection with rheumatism or idiopathically, consist 
chiefly of a dull oppressive pain in the cardiac region, often extending up- 
wards to the shoulder, sometimes backward under the scapula, and not 
infrequently down the left arm, producing a peculiar dull aching pain, 
more particularly between the shoulder and elbow. 

The pulse is usually full, moderately firm under the finger, accelerated 
in frequency to from eighty-five to one hundred beats per minute, respira- 
tions accelerated rather more in proportion than the acceleration of pulse; 
the patient frequently feeling a sense of oppression in his breathing; and 
showing a disposition to have the shoulders elevated and to incline the body 
to the left although not lying over upon the side. There is usually less than 
the ordinary moisture of the mouth, whitish fur upon the tongue, moderate 
degree of thirst, less than the natural flow of urine which is usually deeper 
colored, but little derangement of the alimentary canal, although in most 
cases of an acute character, the appetite is lost and the bowels are a little 
inclined to constipation. The temperature of the body after the first twen- 
ty-lour or forty-eight hours, usually ranges from three to five de- 
grees above the natural standard, varying but little between morning and 
evening. 

None of these general symptoms are sufficiently distinctive in 
their character to enable the physician to render a positive diagnosis re- 
garding the seat of the disease. But by resorting to the physical signs, 
auscultation and percussion, such alterations from the natural sounds and 
movements of the heart may be detected as to add certainty to the diag- 
nosis. First, from the early beginning of the disease in the interior of 
the heart, the impulse against the walls of the chest is increased in force 
and frequency, and auscultation readily detects the exaggerated and more 
blowing character of the first or systolic sound of the heart. This 
may be at first slight, leaving a clearly appreciable interval between 
the first and the second sounds, and usually in from twenty-four to forty- 
eight hours it will have increased sufficiently to be easily recognized as 
the bellows murmur, and sufficiently prolonged to cover nearly or quite the 
interval between the first and second sounds, apparently obliterating the 
latter. This sound is usually heard with most distinctness a little to the 
sternal side of the nipple and directly over the base of the heart, and 
from that dowuward to the left side over the apex. If there be no per- 
icardial complication and effusion, simple inflammation of the endocar- 
dium, does not alter the size of the heart sufficiently to give any in- 
creased area of dullness on percussion. As the disease advances, the 
bellows murmur becomes more and more rough or harsh in its quality, 
and may be heard more distinctly over the apex or immediately below the 
left nipple, but when, as is often the case, the inflammation is limited to the 
semi-lunar valves of the aorta and adjacent parts, an equally distinct and 
rather rough bellows murmur may be traced from the base of the heart 
upward along the course of the aorta nearly or quite to the arch. The 
sound of course diminishes in proportion as we recede from the heart 
itself. In many cases of endocarditis the inflammation extends beyond the 
cavity of the heart along the lining of the aorta, causing more or less 



480 ENDOCARDITIS. 

thickening and roughness of the membrane in this large arten', and in 
such cases the harsh rough sound, synchronous with the systole of the 
heart, may be heard as distinctly or even more distinctly than the ordinary 
bellows murmur over the heart itself. 

It is rare that these sounds are heard as distinctly over the right as over 
the left side of the heart. In cases which prove protracted, extending 
through two, three or four weeks, or as is often the case when 
associated with rheumatism, the alterations of the mitral valve, or the semi- 
lunar of the aorta, and sometimes of both in the same case, become so 
great that the valves fail to close their respective openings during the 
systolic action of the heart, the bellows murmur becomes altered 
in such a direction as to indicate regurgitant sounds. If the alter- 
ations include the mitral valve only, the regurgitant sound will accom- 
pany each impulse of the heart. If the semi-lunar valves of the aorta fail 
in their office the regurgitant sound will be heard more over the base of 
the heart and commencement of the aorta, and will immediately fol- 
low the impulse, being synchronous with the diastole. If the inflamma- 
tion subsides early, the sounds that I have described will usually diminish 
with considerable rapidity, and in the course of two or three weeks may 
entirety disappear. But when the inflammation runs a more protracted 
course, the thickening and induration of the valvular structures and adja- 
cent parts become more permanent, and either perpetuate the sounds 
through a long period of time, or as is not unfrequently the case, fail ever 
to subside entirely, leaving the patient subject to permanent cardiac inef- 
ficiency, aud all those ulterior consequences which will be hereafter de- 
scribed. In cases of very acute endocarditis, after the first few days the 
patient usually becomes extremely depressed, or affected by a sense of 
great weakness, oppression in the chest, a feeling of insufficient respiratory 
movements, and inclination to be bolstered up more in the bed, and to be 
greatly fatigued by any slight exertion. Sometimes getting out of bed 
with the utmost care for ordinary evacuations will lead to panting, hur- 
ried respiration, irregularity and sometimes intermission of the pulse, and 
such a sense of sinking as to be very alarming to the patient. 

Occasionally, in those cases that are severe and accompanied by much 
embarrassment of the heart's action, and probably by more or less exud- 
ation upon the surface of the inflamed parts of plastic material, either in 
minute shreds or patches, or by the formation of fibrinous clots in the 
cavities of the heart, some of these materials are carried from the cavity of 
the heart, by the current of the circulation, into remote organs, constitut- 
ing emboli that are liable to suddenly plug the vessels and thereby in- 
terrupt important functions. Sometimes larger clots form in the cavity 
of the heart and greatly add to the embarrassment of its action, and cause 
some peculiarities in the cardiac sounds. The pulse generally becomes 
very weak and irregular, while the action of the heart is tumultuous, the 
breathing hurried and greatly oppressed, and the countenance expressive 
of great anxiety. Occasionally in these cases larger portions of a fibrinous 
clot in the heart are carried into the vessels, sufficient thus to plug one or 
more of the larger arteries. A case came under my observation within 
the last year, the history of which, as given by the attending physician, 
indicated that during convalescence from a moderate grade of typhoid 
fever the patient had been attacked with endocarditis, followed in a few 
days by the formation of a fibrinous clot in the left ventricle, giving rise 
to an extraordinarily tumultuous action of the heart, and great anxiety in 
the mind of the patient, with a remarkable degree of pulsation throughout 
the whole arterial system of vessels. About the third day there occurred 



SYMPTOMS. 481 

a sudden and entire suppression of the pulse in the right arm. There was 
no other special change in the symptoms but a complete suppression of the 
radial pulse. On tracing the artery upward to its connection with the sub- 
clavian through the axilla, it was found that the obstruction was in the bra- 
chial artery about one inch below the border of the axilla, and was undoubt- 
edly from a clot or embolus carried from the cavity of the heart. About 
two days later, symptoms of plugging of vessels of the brain followed, 
and the patient died. No post-mortem, however, could be obtained. 

In another instance that came under my observation there was every 
evidence, from the physical signs and the symptoms of the case, that ex- 
tensive pulmonary embolism occurred in the progress of endocardial in- 
flammation, which had become complicated with all the signs of a heart- 
clot. Similar cases have not been of frequent occurrence under my 
observation, and yet, that they are liable to occur now and then should 
be borne in mind by the practitioner, and the usual liability to form 
fibrinous exudations, shreds, and larger clots or emboli in the progress of 
endocardial inflammation, should constitute a reason for the practitioner, 
not only to be on the alert for their detection, but it should also lead to 
such treatment of all these cases as would be most likely to lessen the tend- 
ency to the accumulation of the fibrinous elements of the blood, as well 
as to limit exudations of a plastic character. In the great majority of cases 
of endocarditis of an acute or sub-acute grade, whether in connection with 
rheumatic disease or not, the acute stage passes by in from two to three 
weeks; often leaving, however, such changes in the interior lining or valv- 
ular structures as to cause more or less morbid sounds, and impairment 
in the circulation for a much longer period of time. 

These chancres to which I allude consist of the usual thickening- or 
tumefaction and induration of the inflamed structures. The principal 
structure involved is the delicate membrane lining the cavities of the 
heart, and which also constitutes the principal structure of the valves; 
the latter being, in fact, but little else than the lining membrane folded 
upon itself. But while the effects of the inflammation in the membrane 
lining the walls of the ventricles, or covering the columnse carnas, may- 
subside to such a degree as to occasion little or no inconvenience, or even 
disappear wholly, yet after the valvular structures have been in- 
volved, causing them to be thicker, denser and less flexible than natural, 
they usually remain thus mechanically obstructing the free passage of blood 
through the openings of the heart, thereby inducing secondary changes 
which take place slowly at first, but ultimately reach a development that 
seriously impairs the patient's usefulness, and shortens life. 

What was but a slight obstruction to the circulation during the first 
few weeks and sometimes months after the subsidence of the cardiac 
nflammatory attack, becomes in process of time so much increased as to 
have induced increased growth in the muscular structure, constituting hy- 
pertrophy of the walls of the ventricles, more particularly of the left, cor-* 
responding habitual tendency to fullness of the left auricle and pulmona- 
ry veins, thereby producing fullness of the capillaries in the lungs, press- 
ure upon the air cells, difficult or asthmatic breathing, greatly increased 
by attempts to exercise, or whatever tends to increase the frequency of 
the heart's motion, until in a few months or years many of these patients 
become entirely incapacitated for active exercise. When they have 
reached this stage in their progress, there is an almost uniform tendency 
to passive congestion of the kidneys and diminished secretion of urine, 
which added to the irregular and inefficient circulation of the blood, is 
31 B 



482 ENDOCARDITIS. 

soon followed by dropsical effusions. These are first noticed as the pa- 
tient rises from bed in the morning, in the form of fullness or oedematous 
swelling of the loose tissue of the eyelids, and a general appearance of 
iullness of the face. If he is up, with his feet dependent during the day, 
the puffiness of the face and eyelids disappears in a great measure, but as 
night comes on, the feet along tne top and behind the malleoli of the ankles, 
present a swollen appearance which pits on pressure, showing that the se- 
rous effusion has commenced in the lower extremities. 

These slight indications of dropsical infiltration continue slowly to in- 
crease until they exist universally throughout all the areolar tissue of the 
exterior of the body. If left to its own natural tendency, after the ex- 
terior areolar tissue becomes thoroughly oedematous, the serous effusion 
will begin to invade the interior cavities and organs of the body; usually, 
first filling up the peritoneal sac to such an extent as to impede the 
descent of the diaphragm, adding greatly to the oppressed and difficult 
breathing, giving. to the patient an almost constant sense of impending 
suffocation, and terminating finally in one of two ways: — One is by simple 
extension of the oedematous infiltration into the pulmonary tissue, render- 
ing the amount of air capable of entering the lungs so small that the lips be- 
come blue, the extremities cold and purplish, the cutaneous surface covered 
with a cold clammy sweat, extreme sense of suffocation is felt, and a speedy 
death from apncea ensues. The other is by failure of the kidneys to secrete 
urine, allowing the elements of the urine to be retained in the blood until 
their toxemic effect upon the nervous centers induce muscular twitchings, 
drowsiness, irregular and labored breathing, gradually increased to stupor, 
and finally coma and death. 

In some of these cases, during the progress of the supervening coma, 
convulsions occur, sometimes partial but more frequently general 
clonic spasms repeated once or twice, and ending in complete coma, 
relaxation of the sphincters and death. An impression is very general 
among the people that organic disease of the heart renders them liable to 
sudden death at any moment. But so far as relates to death from disease 
of the valves of the heart, originating from attacks of endocardial inflam- 
mation, death is rarely sudden. In much the greater number of this 
•class of patients death approaches slowly, leading them through a pro- 
tracted period of great difficulty of breathing, the constant sense of suffo- 
cation and w T eariness being of such a character that many of them long 
for death to take place weeks before their longing is gratified. I have 
spoken of the symptoms of endocarditis with reference to the separate 
cavities of the heart and the valvular structures, and, as you will have ob- 
served, my references have been almost entirely to the left cavities, with 
the mitral and semi-lunar valves of the aorta. The reason for this is the 
clinical fact that endocardial inflammation very rarely invades the right 
cavities of the heart, whatever may be the physiological reason, whether 
it is from the sedative effects of the increased amount of carbonic acid in 
the venous blood with which the right cavities are filled, or some other 
-cause, all observations show that we have at least fifty cases of endo- 
cardial inflammation in the left to one in the right cavities of the heart. 
But the remote consequences of these inflammations, especially when 
they leave such a condition of the mitral valve as to seriously obstruct 
the auriculo ventricular openings of that side, or cause mitral stenosis as 
it is called, are not restricted altogether to the left cavities of the heart; 
but in many cases of protracted duration the long continued obstruction 
to the passage of blood through the capillary vessels of the lungs leads 
to habitual over-fullness of the pulmonary arteries, and ultimately more 



DIAGNOSIS. 483 

or less of the same increased fullness in the auricles and ventricles of the 
right side of the heart. Most of the post mortem examinations of this 
class of cardiac diseases reveal decided hypertrophy or increased growth 
of the muscular walls of the left ventricle, with diminished size of its 
cavity, while the right ventricle and auricle are both dilated with thinning 
or atrophy of the muscular walls. And usually the dilatation of the right 
auricle and ventricle also includes with it an enlargement of the auriculo- 
ventricular opening, rendering the tricuspid valve insufficient for its 
office, and consequently allowing the regurgitation of blood through it 
with each systole, giving what is familiarly known as the venous pulse or 
regular pulsation in the veins of the neck. Such are the more common 
anatomical changes which result from the different grades of endocardial 
inflammation, involving the valvular structures, and leaving them more or 
less permanently incapacitated for fulfilling their natural office. 

Diagnosis. — The symptoms and physical signs by which we are enabled 
to detect the beginning, and the progress through its subsequent stages, 
of myo- and endocardial inflammation, have been so fully stated in giv- 
ing the clinical history of the disease and its ultimate results that I need 
not re-enumerate them under this head. The principal liability to mis- 
take is in reference to confounding the bellows murmur of endocarditis, 
when of a moderate degree of intensity, with the anaemic bellows mur- 
mur that is met with frequently as the accompaniment of the more 
strongly marked anaemic or impoverished conditions of the blood, uncon- 
nected with any inflammatory action. And, it is a matter of much im- 
portance to be able to distinguish between these two conditions. The 
principal distinctions are, that the anaemic murmur is always synchronous 
with the systolic action of the heart, and is never sufficiently prolonged 
to obliterate the interval between the first and second sounds; but always 
leaves an appreciable interval between them. It is in fact a mere blow- 
ing or exaggeration of the first sound of the heart, its quality neither indi- 
cating roughness, or harshness, nor anything of a regurgitant character. 
Another characteristic of the anaemic bellows murmur, is its being heard 
as loud and plain, and sometimes even more prominently, over the course 
of the aorta as high up as the arch and over the sub-clavian arteries, as 
over the body of the heart itself. If you remember these qualities, with 
the rigid restriction of the morbid sound to the first sound of the heart, 
its softness rather than harsh quality, and its equal development over the 
large arteries, and the further fact, that these anaemic murmurs are in sub- 
jects plainly, either chlorotic or deficient in the red matter of the blood, 
you will hardly be liable to make any mistake in your diagnosis. I may 
add, however, as an almost constant tact, that in endocardial inflammation 
and its consequences the pulse has a pretty uniformly firm, sustained feel- 
ing of tension: whereas, in the anaemic conditions of sufficient degree to 
cause a bellows murmur, the pulse though often excited, quick and having 
the appearance of volume, is nevertheless soft and easy of compression. 

Prognosis. — The prognosis in endocardial inflammation so far as direct 
danger to life is concerned is generally favorable; but in relation to the 
prospect of having complete recovery without embarrassing sequelae, the 
prognosis is not so favorable. A very large proportion of all the cases of 
endocardial inflammation pass through the active stage of the disease with 
safety, and the patient convalesces. In many of them the recovery is 
complete. A large proportion of the cases are nevertheless left with 
some degree of permanent thickening of the valves, which constitutes the 
beginning of that slow morbid process called sclerosis, or increased growth 
of the connective tissue, which will either moderately embarrass them on 



484 EtfDOCAKDITIS. 

taking active exercise through life, or lead to some of those more seri- 
ous structural changes that I have already described as ultimately term- 
inating the life of the patient. Still there are cases of endocarditis of 
such severity as to cause death during the active progress of the disease. 

Treatment. — In Lecture XXXI of the present course, when speaking of 
the treatment of acute articular rheumatism and rheumatic fever, I spoke 
freely of its liability to become complicated with both pericardial and en- 
docardial inflammation. When discussing: the treatment of that grade of 
rheumatism, I called your attention to the additional treatment that 
might be required for the acute stage of these cardiac affections, con- 
sequently it is not necessary to repeat the directions then given at this 
time. (See Lecture XXXI, p. 299.) But the remarks then made were 
limited to the treatment during the acute stage of the progress, both of 
the general rheumatic disease, and of the local cardiac complications. 
The latter, however, are very liable to be continued in what may be styled 
the chronic form, more especially when, during the acute stage, the valvulai 
structures have become thickened and indurated to such a degree as to 
materially interfere with the circulation of the blood. It is then difficult to 
define precisely when the inflammatory action in these cases has ceased, 
and we have only to deal with the consequences, in the form of structural 
changes which the preceding inflammation has induced. But so long as 
there are obscure dull pains in the cardiac region, and slight increase of 
temperature of the body, with some degree of scantiness in the urinary 
secretion, it may be safe to assume that some degree of inflammatory ac- 
tion still exists in the cardiac structure. This inference will be corrob- 
orated in a greater or less degree by the evidence of chronic rheumatic 
inflammation in the articulations, or other fibrous structures in any part 
of the body. So long as evidence of inflammatory action remains, how- 
ever moderate in its degree, there is a tendency to increase or hyper- 
trophy of the connective tissue in the valvular structures, and increase in 
their density, thereby rendering it almost certain that the structural changes 
will become permanent unless counteracted bv persistent treatment. 

It is better, therefore, to err sometimes by continuing treatment de- 
signed for the removal of these low grades of inflammatory action too iong, 
rather than omit it too early. The most efficient treatment during the 
latter stages of the endocardial inflammation, or what might be called its 
chronic stage, consists in the administration of remedies which have a 
two-fold effect, one to lessen the frequency of the heart's action by lessen- . 
ing the irritability of its muscular fibers, and the other to overcome the 
morbid excitability of the inflamed structure and to prevent the further 
atomic or cell changes which take place in all persistent low grades of in- 
flammatory action and constantly tend to increase by hypertrophy the con- 
nective tissue and endothelial layer of the membrane. For these pur- 
poses in the stage of the disease now under consideration, I have seen much 
benefit produced by the administration of the iodide of potassium in con- 
nection with stramonium. A convenient formula would consist of the 
following: 

^ Potassii Iodidi, 10 grams. 3iiss 

Tinctures Stramonii, 12 c. c. 3iii 

Tincturae Digitalis, 30 c. c. §i 

Syrupus Simplicis, 15 c. c. Jss 

Aquse Distillatse, 60 c. c. §ii 

Of this formula four cubic centimeters or one teaspoonful may be given 



TREATMENT. 485 

to the patient every four or six hours, according to the effects of the 
digitalis upon the motions of the heart. At the same time it is desirable 
to continue the use of the alkaline carbonates, either of potassium or so- 
dium, with sufficient degree of freedom to prevent the urine from again 
becoming 1 more than normally acid. These remedies will usually keep 
the urinary secretion free in quantity, lessen the cardiac excitement, favor 
tiie disappearance of what rheumatic pains and soreness may still he lin- 
gering in any part of the system, while the alterative effects of the iodide 
are particularly calculated, not only to prevent further inflammatory exu- 
dation into thi valvular textures, but to aid in causing the disintegration 
and removal of su -h as have already taken place. 

In sjme of these cases, the .bowels remain costive unless they are 
prompted by some laxative. In such cases a pill composed of blue mass, ex 
tract of hyosciamus, and aloes six centigrams (gr. i) each given at night will 
usually produce a moderate evacuation in the morning, which is all that is 
necessary. I have seen some cases of endocardial inflammation arising 
in the progress of acute rheumatic disease in which the faithful and some- 
what persistent use of the remedies here indicated was followed by an en- 
tire removal of the physical signs of valvular thickening, and of all ob- 
struction to the free circulation of the blood through the various cavities 
and openings of the heart. On the other hand it must be acknowledged 
that there are many of the cases which resist all efforts to remove these 
inflammatory changes. The consequence is, that the patient recovers 
sufficiently to resume more or less attention to business, or ability to take 
moderate exercise indoors and out, but yet, the cardiac murmurs remain, 
the pulse retains the characteristic qualities that belong to obstructions 
in the mitral and aortic, openings, and the patient sooner or later again 
finds himself incapable of taking active exercise or of ascending stairs with- 
out feeling oppressed in breathing, with increased frequency and irregu- 
larity of the heart's beat. The question how best to manage these cases 
for the purpose of preventing ulterior changes in the cavities of the heart 
and their consequences, is one of much practical importance. 

My own experience has led me to think the practitioner should give 
special attention to the accomplishment of three objects in the manage- 
ment of such cases: — First to carefully instruct the patient in regard to 
the importance of so regulating his daily habits of life as to avoid, as 
much as possible, all mental excitement or anxiety on the one hand, and 
hurried or exaggerated physical exercise on the other; such occupations as 
will afford his mind employment without intensity of application or much 
anxiety in regard to the results to be obtained, and the regulation of exer- 
cise in such a way as to enjoy the open air passively by riding and moder- 
ate walking, but avoiding the ascent of hills and steep places out of doors, 
and, as much as possible, the stairs within doors. Whenever the latter is 
attempted it should be done with much deliberation and slowness. In 
other words the patient should be instructed to do all his work, both men- 
tal and physical, in quietude, and entire freedom from hurry or violent 
exertion. By such a regulation of the daily habits very much will be 
gained in retarding the progress of the cardiac changes. The second 
important object to be accomplished is the use of such remedies as will be 
most efficient in keeping the frequency of the heart's beat as near the 
natural standard as possible. When the mitral valve performs its office 
imperfectly or the auriculo- ventricular opening is contracted, constituting 
mitral stenosis, the more frequent the systolic action, the less time there 
is for the blood to pass from the auricle through the narrow opening into 
the ventricle. Hence it is that every excitement or exertion that quick- 



480 ENDOCAKD1TIS. 

ens the systolic action in such patients brings oppression in breathing, and 
quickly causes them to demand rest. If the systolic action can be ren- 
dered slow, leaving the full length of interval between the systole and 
diastole, the blood passes in larger quantity through the narrow opening, 
the ventricle becomes better filled, a fuller volume of blood is sent to the 
system at large, and the pulmonary circulation is relieved. It is desirable 
however, in selecting remedies for those cases, that they be such as will 
render the action of the heart slower without impairing its force. 

It is also desirable that they should be exempt from liability to 
disturbance of digestion or interference with the functions of the stomach. 
You will perceive that the cardiac sedatives, such as veratrum viride, aco- 
nite, and gelsemium, are not well adapted to these cases. For, while they 
are efficient in rendering the heart's action slower, they tend both to dimin- 
ish the muscular force, and to disturb the functions of the stomach, unless 
they are administered with great caution. Digitalis, cactus grandiflora, 
and convallaria, are almost the only remedies with which we are familiar 
that possess all the desired qualities, and can be used for the required 
length of time in such a way as to regulate the heart's action and greatly 
ameliorate the condition of the patient, and at the same time retard the 
ulterior changes to which such cases are always liable. In many instances 
I have used a combination of one part of the tincture of digitalis with two 
parts of the fluid extract of Scutellaria, giving of the mixture two cubic 
centimeters (min. xxx) every four or six hour? until a perceptible slowing 
of the cardiac action was obtained, when from two to three doses in the 
twenty-four hours would usually perpetuate the effect desired. The fluid 
extracts of the cactus and of the convallaria have not been sufficiently 
tested in these cases to justify me in speaking very positively of their 
effects. 

I think they are less reliable than digitalis, but maybe used for a longer 
period of time without danger of accumulating and suddenly developing 
exaggerated effects, as digitalis occasionally does. The third object which 
the practitioner should keep in view in all these cases, is the regulation of the 
diet, clothing, and other hygienic conditions of his patient, with a view of 
preventing the recurrence of rheumatic attacks during the transition sea- 
sons of the year, to which almost all such cases are more or less liable, and 
which seldom fail to increase the local cardiac changes. This object will 
be accomplished best by requiring the patient to wear flannel or other good 
non-conductors of heat and electricity next to the surface during all the 
year, unless it be a few weeks in the middle of the summer when it should 
be exchanged for the lighter canton flannel. Another item of a hygienic 
character of much value to such patients is the use of a warm alkaline bath 
once or twice a week, particularly during the cold season of the year, 
from the first beginning of the cool and the wet weather of autumn, until 
the return of the following summer. These baths may consist simply of 
warm water holding in solution sufficient of the carbonate of sodium or 
potassium to render them alkaline, and after the patient has been im- 
mersed in the bath as long as is comfortable, on removal, the water should 
be wiped quickly from the surface with ordinary towels, and the whole 
cutaneous surface briskly and rapidly rubbed with dry soft flannel. In 
this way the skin can be kept healthy and active, which constitutes the 
most efficient safeguard against the accumulation of the lactic acid or 
other materials in the blood supposed to be capable of causing rheumatic 
inflammation. I have seen many patients who by systematic careful man- 
agement on the principles I have indicated, have passed from ten to thirty 
years of life with a reasonable degree of comfort, and have been able to 



TREATMENT. 487 

pursue successfully their ordinary occupations after the establishment of 
permanent cardiac murmurs. 

One of thorn, a lady, has during the time reared a family of children, 
superintending her own household, always preserving calmness and 
quietude in her movements, mental and physical; and though many times 
laid up temporarily with fresh rheumatic attacks of a mild character, in- 
volving each time increased cardiac excitement and some increased bel- 
lows murmur, yet warding them off by such means as I have indicated, she 
continues still able to endure a moderate degree, of walking, any amount 
of riding, and to enjoy life to a reasonable extent. But if these cases are 
not carefully guided by accurate instructions, much the larger proportion 
of them will have their cardiac troubles increased two or three times dur- 
ing every cold season of the year, and they speedily reach that degree of 
exaggeration which brings general dropsical infiltration, and entire failure 
of the patient. 

Inflammation of the Aorta. — Acute or sub-acute inflammation of the 
lining membrane of the aorta rarely occurs except in direct connection 
with endocarditis. I have seen a few cases, however, that occurred during 
the progress of acute rheumatic attacks in which all the physical signs of 
thickening of the membrane lining the aorta, such as harsh rough 
sounds in connection with the systolic action of the heart, decided sense 
of oppression, distress in the chest behind the sternum, and, as the cases 
progressed, more or less difficulty of breathing, decided expression of 
anxiety in the countenance, and an exaggeration of the pulsations in 
the carotid and sub-c!avian arteries indicative of actual inflammatory action 
in the larger vessels, and yet close examination by auscultation failed to 
detect the cardiac sounds characteristic of endocardial inflammation. 
The rough sounds heard over the aorta at different points from the semi- 
lunar valves at its opening to its arch, were not detected over the body of 
the heart, or at the apex. In one of these cases to which I allude, the 
patient being under my care in the hospital, there occurred indications in 
connection w r ith it, of a moderate degree of pneumonic inflammation in 
the left lung. The case proved fatal about the end of the second week of 
the rheumatic affection, and I think on the seventh day after the physical 
signs indicated involvement of the aorta. When inflammation takes place 
in the lining of the aorta, it produces the same changes anatomically, that 
take place in the interior of the cavities of the heart. The membrane, 
or parts of it, become thickened and often studded with little prominences 
made up of the proliferating endothelial cells, and sometimes apparently 
springing from the deeper layers of the connective tissue. 

Very few of these cases have terminated fatally during the active stage. 
[ am quite sure that I have traced a few of them, however, in their subse- 
quent course to the establishment of permanent rough places in the interior 
of the aorta, causing harsh rough sounds sjmchronous with the systolic 
action of the heart, keeping up more or less feelings of oppression and 
fullness in the chest which were much increased by exercise. It is highly 
probable from the appearances found on post-mortem examinations that 
these rough places are patches of increased thickening of the structure, and 
which in time present more of an atheromatous character. It is also 
probable that in some instances these atheromatous changes extend deep 
enough into the arterial coats to impair their strength and thereby prepare 
the way for the development of future aneurismal dilatations. The 
treatment in these cases of inflammation in the aorta is similar in all res- 
pects to the treatment of the same grades of endocardial inflammation. 



488 ULCERATIVE ENDOCARDITIS. 

Acute Ulcerative Endocarditis. — There is still another form of inflam- 
mation affecting the endocardium requiring a brief notice. It has been 
recognized as a distinct form of endocarditis only the last few years. I 
allude to what some recent writers have styled "acute ulcerative endo- 
carditis." It occurs chiefly as a complication in the advanced stages, or 
during the early part of convalesence, of the general acute infectious dis- 
eases; such as diptheria, pyaemia, typhoid fever, and probably never 
occurs as an idiopathic affection unless preceded by some form of blood 
poisoning. The symptoms of the disease are often obscure so far as the 
inflammation of the heart is concerned. Generally the first noticeable 
symptoms are the chill, followed bv an unusually high fever, the tem- 
perature rising rapidly to 40°— 40".5° — 41 ° C. (104-5— 6° F.), the pulse 
becoming exceedingly rapid, soft or easily compressed, feelings of great 
prostration, not unfrequently vomiting, accompanied by extreme distress 
in the epigastrium, and in other instances diarrhoea, and occasionally diar- 
rhoeal discharge mixed with blood. The urinary secretion becomes very 
scanty and in most cases more or less albuminous. The progress of these 
cases is usually rapid; the patient, more generally on the second or third 
day, becomes delirious, pulse small, thready, extremities cold and bluish; 
in some cases purpuric or hemorrhagic spots appear upon the surface, par- 
ticularly over the abdomen and inner surface of the thighs; the heart's 
action is very weak, at times intermitting and sometimes tumultuous, but 
generally growing hourly more feeble till the patient sinks into a drowsy, 
or comatose condition and dies. There are some cases, however, in which 
the symptoms are less severe and the progress less rapid, presenting some 
resemblance in their clinical phenomena to the more severe grades of 
typhoid fever. In others, they have been so similar to the progress of 
cases of pyaemia and septicaemia that no differential diagnosis has been 
made during life. Even auscultation, here, does not always furnish the 
bellows murmur, or the altered sounds which are characteristic of inflam- 
mation in the interior of the heart. In one or two instances that have 
come under my own observation, in which the patients were not seen until 
the disease was near its fatal termination, the cardiac action was so weak 
and rapid as to render it impossible to analyze the sounds. It was easy to 
determine that they were abnormal, that there was an unnatural condition 
of the interior of the heart, but I could not distinguish clearly the sounds 
belonging to different parts of the rhythm of the heart. 

This form of endocarditis pretty uniformly terminates fatally. The 
anatomical changes that accompany it, are found to consist of little reddish 
and sometimes gray granules, sometimes arranged in rows on different 
parts of the interior surface of the left ventricle. Generally these granules 
are more readily seen on either the mitral or the semi-lunar valves of 
the left side of the heart. The granules are easily rubbed off, leaving the 
surface on which they rested covered with minute ulcerations. Some- 
times these ulcerations enter quite deeply into the valvular structure. A 
few instances have been observed in which they had penetrated 
through the whole depth of the valve, causing perforations. 
In more cases they had penetrated only deep enough to 
weaken the valves and cause a bulging, and sometimes aneuris- 
mal dilatation. When the mitral valves have been thus weakened the 
bulging is toward the auricle ; the same change taking place in the sem- 
ilunar valves, the bulging is toward the cavity of the ventricle. Micro- 
scopic examination of the granulations I have mentioned, and also the 
surface of these ulcers, and often in part of the structure constituting the 
interior of the heart, shows the presence of great numbers of the spheri- 



TREATMENT. 489 

cal bacteria or microccoci. They seem to exist in clusters ; indeed the 
apparent granules are largely made up of collections of these micrococci, at 
the same time they are found in large numbers in the blood taken from 
any part of the body, and generally maybe found also in the other tissues. 
How far they have any causative relation to the end ocardial disease is not 
known. This form of endocarditis has not been definitely diagnosticated 
except in those instances where the blood of the patient was contaminated 
with some form of septic or poisonous material. 

And in all such cases, more or less of the bacterial forms have been 
found present wherever microscopic examinations have been made by 
those competent to observe. Yet their presence in these cases by no 
means justifies the conclusion that they are the cause of the disease, either 
of the blood generally, or of the local affection of the heart. A very in- 
teresting and marked complication which occurs with many of these cases 
of acute ulcerative inflammation of the endocardium, is the formation of 
multiple abscesses ; not in the heart structure, but they are found in dis- 
tant organs. The organs most frequently exhibiting these small abscesses 
are the spleen, kidneys and liver. Whether such abscesses are produced 
by the invasion of some of these detached granules containing the micro- 
cocci, or by minute emboli formed in the heart, or whether they originate 
from the same condition of the blood which had produced the endocar- 
dial disease, investigation has not determined. Neither is it a point of 
much practical importance. As I have stated these cases of ulcerative 
endocarditis have thus far uniformly terminated fatally ; no treatment 
having proved successful, and from the very nature of the case there is no 
reasonable probability that treatment will ever succeed in correcting the 
morbid condition in time to prevent the death of the patient. The most 
important direction to be given in regard to the management of these 
cases, is the use of such remedies in each individual case as the more 
prominent symptoms may indicate ; always keeping in mind that the 
liberal use of such antiseptics and germicides as can be introduced into 
the blood rapidly and with safety, and in addition such remedial agents as 
directly tend to support the strength of the patient, and as far as possible 
maintain the nutritive processes, will afford the best chance, both of palli- 
ating the patient's condition, and producing recovery, if the latter were 
possible. In other words the treatment is really the same as that which 
is required in the more severe cases of pyaemia and other well known 
forms of blood poisoning. I have now completed the consideration of the 
inflammations liable to affect the central organs of the circulation. 



LECTURE L 



Inflammation of the Organs of Digestion; the several.'parts or structures included— Inflammatory 
affections o! the mucous membrane of the mouth, and fauces and its appendages; their clinical 
history, diagnosis and treatment. 

GENTLEMEN: The digestive apparatus includes the mucous membrane 
of the mouth and fauces, the salivary glands, the tonsils, the tongue, 
oesophagus, stomach, duodenum, small intestines, colon and rectum, togeth- 



490 STOMATITIS. 

er with the glandular organs connected therewith, the more important of 
which are the liver, spleen, pancreas and mesenteric glands. Inflammation 
in its various grades of activity may occur in any and all of these portions 
separately, or it may occur in several of them simultaneously. I shall 
consider them, however, as they relate to each of the prominent divisions 01 
the apparatus already mentioned, commencing with the mouth. 

Stomatitis. — Many writers use the word stomatitis to designate all the 
various grades of inflammation in the mucous membrane of the mouth. 
For practicable purposes, we may include these several inflammatory con- 
ditions under the following heads: Diffuse or superficial inflammation, 
apthous and follicular, mercurial, nursing, scorbutic, ulcerative, and gan- 
grenous. The first grade of inflammation mentioned, that of diffuse su- 
perficial inflammation of the membrane lining the mouth, occurs in two 
essentially distinct conditions of the system. The first is the result usu- 
ally of the action of some local irritant applied directly to the membrane 
itself, and may occur in any or all classes of subjects. The taking into 
the mouth of substances at too high a temperature, producing slight 
scalds or burns ; the use of irritating liquids, or anything in contact with 
the membrane of the mouth which is capable of producing irritation, may 
cause this form of disease. It is much more frequently caused by the 
simple taking of liquids too hot, and the incautious use of certain acid 
substances not sufficiently diluted. The symptoms which accompany 
this form of inflammation are a sense of heat, at first dryness, followed 
by increased flow of saliva, and soreness of the inflamed membrane, while 
to the eye it looks red, and slightly tumefied. There are some substances 
capable of exciting superficial inflammation of the membrane when ap- 
plied to it, that instead of being followed by redness, seem to contract the 
vessels of the surface and so alter it as to cause increased paleness or a 
white instead of a red and congested appearance. Such is the case 
with the application of carbolic acid of sufficient strength, and of creasote. 
When the inflammation is simply of a superficial character, arising from 
any of the various causes to which I have alluded, it usually runs its 
course and subsides with little or no treatment in a few days. When it 
is more severe, however, and the services of the physician are required, on 
account of the intensity of the hot, burning, smarting pain, and the incon- 
venience that the patient suffers, one of the best remedies will consist in 
use of a cold mucilaginous infusion to be held in the mouth as much of 
the time as the patient can make convenient. The mucilage of the gum 
arabic, ulmus fulva, or of Symphytum officinale (comfrey) rendered cold by 
small pieces of ice, are among the best applications that can be used lo- 
cally. After the first stage of the inflammatory action is passed and the 
heat and smarting pain are less severe or have passed away, if there is 
left some blush of redness, with tenderness, or the contact of food is 
painful, with a disposition to excessive flow of saliva as sometimes hap- 
pens, from the orifices of the salivary ducts being involved in the inflam- 
mation, an infusion prepared by putting the coptis or gold thread root 
and sage leaves each four grams (3i) and borate of sodium six decigrams 
(gr. x.), into an ordinary tea-cup, two thirds full of boiling water, to which 
may be added a little white sugar or honey, and the mouth freely rinsed 
or gargled with it every three or four hours during the day will give 
additional relief. If at any time during the progress of the case the 
patient's bowels are found to be inactive, or if any feverishness is mani- 
fested, it will be well to give a dose of some saline laxative, sufficient to 
procure from one to three intestinal evacuations. In the great majority of 
cases any one of the local remedies I have named, together with the use of 



THRUSH OR MIGUET. 491 

as bland, anirritating nourishment as possible, will constitute all the treat- 
ment that will be needed, The other variety of diiFuse superficial inflam- 
mation is limited in its occurrence almost entirely to patients suffering from 
imperfect nutrition. The great majority of cases are in young children, 
commencing before the end of the first week after birth; and are caused by 
a failure of nutrition, either from the reception of an insufficient supply of 
milk, or an inability to assimilate what it does receive. Under such cir- 
cumstances, somewhere from the second to the fifth day, the child's mouth 
begins to show a general increase of redness of the mucous membrane, and 
during the next twenty-four hours this membrane will become dotted 
over with small specks of a white curdy exudation upon the surface; or 
it may be so completely covered with the exudation as to render the whole 
surface of the mouth, gums, edges of the tongue back to the fauces, 
completely white. But if there are any places where this white covering 
is either detached or scraped off, the membrane itself will be seen red and 
slightly tumefied. This condition of the mouth in nursing children is 
familiarly called thrush/ and by the French, miguet. 

In many of them, soon after this condition of the mouth appears, the 
the skin shows a peculiar sallow hue somewhat resembling jaundice, and 
dark purplish red spots make their appearance upon the skin, more partic- 
ularly over the face and upper part of the chest. When this alteration of 
color in the cutaneous surface and the red spots appear, the nurses call it 
red gum. Most of the children suffering from the disease to the extent 
I have indicated, are drowsy or inclined to sleep, sometimes to such an 
extent as to make it difficult to arouse them sufficiently to take nourish- 
ment either by nursing or from the spoon when fed. Very generally, the 
bowels are at first inactive, the urinary secretion scanty, and in some in- 
stances suppressed. 

My attention was called to a child only three days old, a few weeks 
since, in which the bowels had not moved for forty-eight hours, and there 
had been no secretion of urine whatever during the whole period of tim^. 
The child wa3 exceedingly drowsy, had all the symptoms of thrush and 
the red spots upon the skin which I have mentioned, but gave no signs of 
uraemic disturbance except an occasional sudden starting from the drowsy 
condition, and immediately lapsing into it again. In most of these cases, 
about the third da} 7 after the appearance of the curdy exudations upon the 
surface of the membrane lining the mouth, it begins to disintegrate, and dur- 
ing the next two or three days it usually disappears. If the patient has 
been improving as these exudations disappear, the membrane of the 
mouth then shows more nearly a natural color; the breath is free from of- 
fensiveness, and all the symptoms of disease speedily disappear. But in 
cases in which the cause of the difficulty has not been removed, the disap- 
pearance of the curdy exudation is accompanied by a slight offensive 
odor, with superficial abrasions of the mucous membrane, particularly 
along the edges of the tongue, the gums, and sometimes on the inside of 
the lips and the central part of the cheek, constituting the slightest form 
of the ulcerative abrasions of the membrane of the mouth. The other 
circumstances in which this same form of inflammation of the mouth oc- 
curs in adult life, are extreme emaciation from the influence of some pre- 
existing disease, such as tubercular phthisis, chronic diarrhoeas, dysentery, 
or any other form of disease that is capable of producing extreme im- 
poverishment of blood and wasting. 

When this stage of extreme impoverishment supervenes, in the progress 
of wasting diseases the patient generally complains first of simple tender- 
ness and heat in the mouth, as if it had been slightly burned. On inspec- 



492 STOMATITIS. 

tion, the membrane covering the fauces and usually the edges of the 
tongue, will be seen unnaturally red, with small patches of a white curdy 
exudation on its surface. In some cases these patches increase in size 
until, as in the very young children, a large part of the membrane be- 
comes white with it. In this class of cases the disappearance of the 
exudation is almost always followed by more or less destruction of the 
membrane, leaving irregular superficial ulcerations, which cause the pa- 
tient much inconvenience and suffering in attempting to take food and 
drink. The disease in these cases has no natural tendency to recovery or is 
not self-limit in duration unless the associated general disease which has led 
to the impoverishment is capable of removal; when this is the case, the 
disease in the mouth ceases spontaneously, simply from the removal of its 
cause. As both the thrush or curdy sore mouth of infancy, and that which 
occurs in adult life, originate from defective nutrition, the primary object 
of the treatment must be to restore this process to the healthy natural 
standard of activity. All local applications will be merely palliative in 
their effects. In young children the most important item in their man- 
agement is to secure for them a good supply of healthy mother's milk. If 
the natural mother, from defects in the nipples, or from inflammation affect- 
ing the mammary glands, or any other cause, is rendered incapable of fur- 
nishing the necessary nourishment to the child, it will be of great advan- 
tage if a healthy w r et nurse can be found to take her place. When this 
is inconvenient or impracticable, the next best resort is the use of fresh, 
pure cow's milk, to which may be added a tablespoonful of lime water, 
to each teacupful of milk, and just enough of either sugar of milk, or ordi- 
nary white sugar, to give it a slightly sweetish taste. By this degree of 
dilution, and the addition of a small proportion of sugar, the composition 
of the cow's milk is brought as near to that of the mother's or human milk 
as can be conveniently done; while the use of the lime water as a diiutent, 
instead of pure water, gives the additional advantage of rendering the 
ooagulation of the casein in the child's stomach slower, and therefore less 
likely to occur before absorption can take place. 

In the absence of the ability to nurse, the rule for feeding the child 
should be to give it just such quantities, and with such frequency as will 
appear to satisfy its appetite. I know of no arbitrary rule that can be 
given for the frequency of feeding infants. They differ much, one from 
another, in the frequency of their demands for food. Usually, when they 
are well supplied, they will be quiet, good-natured, and rest well. But if 
not fed enough, or fed on material so diluted that the tissues are starved 
when the stomach is full, they will persistently cry or worry until they 
have a better supply. And yet both mothers and nurses sometimes mis- 
take the crying as indicative of colic, and dilute the food still more, only 
to be annoyed by the increased restlessness and worrying of the child. 
After providing the child with an adequate amount of some proper form of 
nourishment, the only other remedies required, usually, are such as will 
secure a moderate movement of the bowels about once in twenty-four 
hours, and promote the renal secretion where this is defect- 
ive, internally, and the application of some very mild, slightly astringent 
solution to the mouth. The best laxative in most cases where this is re- 
quired consists of an infusion of manna, anise seed, and soda. Four 
grams (3i) of manna, half that quantity of anise seed, bruised, andfive deci- 
grams (gr. viii) of bicarbonate of sodium may be put into one hundred cubic 
centimeters (|iii) of water boiling hot; stir it up frequently till it is cool; add 
a little white sugar, and feed the baby a teaspoonful of this infusion every 
two hours till the bowels are moved. If the kidneys need prompting, the 



FOLLICULAR STOMATITIS. 493 

addition of from one to two minims of nitrous ether (sweet spirits of 
nitre) to each dose of the laxative will have the desired effect. After the 
howds have been moved once or twice, and the urinary secretion rendered 
sufficient, if the child appears debilitated, with coldness of the extremities, 
from two to five minims of the compound tincture of cinchona may be 
given in half a teaspoonful of sweetened water every four or six hours. 
For local application to the membrane of the mouth I have found nothing 
more beneficial or more easily applied than a powder composed of 
alum six decigrams, saccharum alba (white sugar) eight grams, a small 
portion of which on the point of a penknife may be passed into the 
mouth of the child, or be placed upon the child's tongue, three or four 
times a day. The powder quickly dissolves and diffuses itself into the 
mouth more perfectly, and consequently becomes applied to the inflamed 
surface more efficiently than can be done by any process of swabbing 
which is so frequently resorted to by nurses in these cases. Indeed, the 
frequent introduction of the ordinary swab for applications in this class 
of cases is usually productive of much more harm than good, from the 
mechanical irritation induced. 

. No apprehension need be felt concerning the child's swallowing the 
dissolved powder, for the small portion of alum that would be con- 
tained in any one of the applications would have no perceptible 
effect upon the child's stomach. Usually the exudations rapidly dis- 
appear under this treatment, no ulceration follows, and no additional 
local applications are necessary. If, however, as occasionally happens, 
the disappearance of the exudation is accompanied by more or less offen- 
siveness of the breath and saliva, and the membrane remains tender, or 
slightly abraded, it will be well to have the affected surface wet three or 
four times a day with the infusion of coptis or gold-thread, sage, and borax, 
to which I alluded a few moments since. In those cases of this variety 
of sore mouth occurring in the advanced stage of wasting diseases, the 
same local applications will be found as beneficial as any that can be 
used. The internal treatment must be guided entirely by the more prom- 
inent disease which has occasioned the emaciation and suspension of 
nutrition. 

Follicular Stomatitis. — By follicular inflammation of the mouth is 
meant those cases in which the inflammation is limited to the follicles in- 
stead of its diffusion over the membrane generally. This form of inflam- 
mation is indicated by the appearance on some portions of the fauces, in- 
side of the cheeks, inside of the lips, and on the tongue, of little red prom- 
inences accompanied by a sense of heat, tenderness on taking food and 
drinks intc the mouth, and generally, after the first day, an increased flow 
of saliva, if the lollicular disease has resulted, as is often the case, from 
derangements of che functions of the stomach and the processes of diges- 
tion, it will speedily disappear whenever these derangements are corrected. 
Jn most instances its natural tendency is to continue no more than from 
three to five days and disappear, leaving no ulcerations or abrasions of 
the membrane. Another variety of inflammation more troublesome, from 
its tendency co be more protracted in its duration than the follicular, has 
been termed apthous inflammation of the mouth. This appears, first, in 
the form of distinct vesicles, generally strictly oval, varying in size from 
a millet seed to the circumference of a small pea, filled at first with a 
transparent rather viscid fluid. If examined during this follicular stage 
there will usually appear a slight areola of redness, directly around the 
base of the visicle. 

In the slightest forms of the disease, not more than one or two of these 



494 STOMATITIS. 

vesicles will appear at a time in the mouth. In other cnses there may be 
three, four or five vesicles closely aggregated together, constituting a 
group, or there may be several of these groups in different parts of the 
mouth. Perhaps they more frequently appear on the inside of the lips 
and cheeks than elsewhere. When they occur in clusters, the inflamma- 
tion is more severe; not only causing redness in a narrow areola around 
their base, but causing some actual tumefaction and slight hardening of 
the parts on which the vesicles rest. The walls of the vesicles are usually 
broken by the motions of the mouth, in taking food, within the first 
twenty -four or thirty-six hours after their appearance. When the walls 
of the vesicles have broken and disappeared there is left a slightly ex- 
cavated ulcer, with usually irregular edges, its surface being covered with 
a very thin white exudation; giving it the appearance of an excavated 
irritable ulcer, surrounded by a narrow line of redness. These are ex- 
tremelv irritable, causing- a feeling of burning smarting- sting-ing, great- 
ly aggravated whenever the patient makes those movements necessary 
in talking or taking food and drink. In most cases they soon manifest a 
tendency to undergo repair and cicitrization, and make sufficient progress 
to render the process of recovery complete in from five to nine days. 
Where they occur, however, in patients affected by an unhealthy consti- 
tutional condition, whether scrofulous, or simply impaired by bad sanitary 
surroundings, such as residence in impure air, damp, and cold rooms, 
and the use of indigestible, or insufficient nourishment, the ulcers left 
by the disappearance of a group of vesicles under such circumstances, in- 
stead of putting on a granulating aspect and progressing toward recov- 
ery, slowly spread until sometimes they occupy the whole diameter of 
the inside of the cheek, or a large portion of the inner surface of the lip; 
keeping up a constant flow of saliva, accompanied by some degree of offen- 
sivene^s of the breath and of the salivary secretion. Nearly all the cases 
of apthous inflammation of the mouth have for their cause derangements 
of the digestive organs of such a character as to produce an undue amount 
of acidity of the stomach, generally associated with constipation, though 
occasionally the reverse condition of the bowels will exist. 

The treatment required both for the follicular and apthous forms of in- 
flammation in the mouth, should have for its object, first, the correction 
of whatever derangements in the function of the stomach and digest- 
ive apparatus may exist, the removal of the patient from whatever 
bad sanitary conditions he may be placed in, the supply of a sufficient 
quantity of good, easily digested food, and such local applications as will 
directly diminish the morbid sensitiveness of the inflamed follicular or 
apthous ulcers, and establish a new or healthier molecular movement 
in them. In the simple follicular grade of inflammation mucilaginous or 
slightly astringent washes will constitute all the local applications re- 
quired. But the apthous ulcers, after the vesicles are broken, will be 
most speedily changed to a condition of repair and freedom from sensitive- 
ness or pain by touching them once or twice in the twenty-four hours with 
a smooth pencil or crystal of the sulphate of copper. Placing the smooth 
surface of the solid sulphate of copper for one or two seconds directly upon 
the surface of the apthous ulcer, while it produces momentary smarting, 
is almost invariably followed in the course of an hour by a great mitiga- 
tion of the burning, and all other painful sensations. Repeating this ap- 
plication once or at most twice a day for the first three days is usually 
sufficient to cause a rapid disappearance of the ulcer. Many recommend 
an application of a pencil of nitrate of silver to the surface of these ulcers 
instead of the sulphate of copper. And many use, instead of either mildly 



MERCURIAL STOMATITIS. 495 

astringent and antiseptic washes, such as solutions of the sulphate of zinc, 
sulphate of iron, permanganate of potassium, or some one of the vegetable 
astringents. Of these, the nitrate of silver is by far the most efficacious. 
But, so far as my observation goes, this is not as uniformly and promptly 
beneficial as the application of the sulphate of copper in the manner I 
have already mentioned. It generally blackens whatever it touches, mak- 
ing it very unpleasant to use, and as it possesses no advantage in a cura- 
tive aspect, over the sulphate of copper, the latter should be preferred. 
Many of these apthous ulcers may be relieved, though a little less speed- 
ily, by touching them with a crystal or pencil of the sulphate of aluminium 
(alum). If this is used it should be held in contact with the ulcerated 
surfaces a longer time than the sulphate of copper; but it will not be found 
as promptly beneficial. 

Mercurial Stomatitis. — In former years, when the mercurial prepara- 
tions were much more freely used in the treatment of disease than at the 
present time, a severe inflammation of the mucous membrane of the mouth, 
gums and fauces, was not un frequently induced, and was known by the 
familiar name of salivation. There are a few persons possessed of such 
idiosyncrasy, that even the smallest quantity of mercurials taken internally 
will speedily result in the establishment of an inflammation in the mucous 
membrane of the mouth, together with more or less irritation of the sali- 
vary glands. But, without any such idiosyncrasy, it is well known that 
the continued administration of small doses of mercurials, more particu- 
larly of the mild chloride, blue mass, and the iodides, is liable to develop 
this inflammation to a greater or less extent. The first symptoms of the 
presence of this form of inflammation are tenderness in the sockets of the 
teeth, a peculiar fetid odor of the breath, and a slightly swollen and bluish 
line along the edges of the gums around the teeth. The observant prac- 
titioner may frequently detect this odor of the breath, and note the change 
in the appearance of the edge of the gums before the patient has suffered 
sufficient inconvenience to attract his attention. But, from this slight 
beginning, if the remedy has been administered in sufficient quantity 
and suffered to accumulate in the system, the inflammation will extend 
over the entire mucous membrane of the mouth, causing it to become red- 
dened and swollen, with tumefaction of the tonsils and fauces, and an in- 
creased flow of saliva. 

In bad cases, four or five days after the commencement of the inflam- 
mation, a large portion of the teeth will be found loose, the gums swollen 
and commencing to ulcerate, with superficial ulcerations along the inside 
of the cheeks and lips and over the fauces, which together with the swell- 
ing of the salivary glands, will often impede the opening of the mouth 
beyond a very limited extent, and occasion a constant flow of saliva. 
There is a sense of heat, burning, and often decided pain, particularly in 
the fauces, along the roots of the teeth, sometimes radiating through the 
branches of the nerves supplying not only the teeth, but the sides of the 
face, even up through the temples and backward over the mastoid region. 
In the more severe cases the tongue partakes of the inflammation and be- 
comes much swollen; adding to the difficulty of swallowing or taking 
either nourishment or medicine; sometimes preventing the patient from 
closing his mouth, and keeping the swollen tongue constantly protruding 
beyond the teeth and suspending the ability to perform deglutition, as 
well as occasioning considerable difficulty in breathing. In all these cases 
the breath and saliva have a very offensive odor, so peculiar as to be at 
Dnce recognized by the practitioner as diagnostic of this form of disease. 
When the mercurial, which has been the cause of the disease, has not been 



496 STOMATITIS. 

administered after the supervention of the symptoms of salivation, the 
usual tendency of the inflammation is to reach its climax of severity in 
from three to five days after its commencement. In the milder class of 
cases soon after this, it spontaneously begins to decline, all the unpleasant 
symptoms diminish from day to day, and at the end of the second week 
the mouth will generally have returned to its natural condition. In the 
more severe cases, however, the climax of the tumefaction of the tongue, 
and parts inflamed throughout the mouth, will not be reached until from 
seven to nine days. And in some cases, when this climax is reached, the 
symptoms continue with but little abatement for almost as much longer, 
and then slowly decline, until at the end of from four to six weeks all the 
more important consequences of the inflammation have disappeared. I 
have not known any cases of mercurial salivation to terminate fatally. But 
when the inflammation has been very severe and protracted, the gums 
have been so far destroyed, and the teeth loosened from their sockets, that 
it became necessary for their removal; in some instances the inflammation 
has extended to the periosteum of one or both jaw-bones, ending in more 
or less necroses. 

Such is the general course of the different degrees of salivation, or in- 
flammation induced by the incautious use of mercurials. Forty years 
since, during the earlier years of my professional life, I saw many cases il- 
lustrating all the various grades of inflammation produced by mercurials. 
But the change which has taken place in the administration of this class 
of remedies has been such that I have met with very few instances, and 
these of the milder character, during the last twenty-five years. 

Treatment. — In the treatment of mercurial inflammation of the mouth, 
of course the further use of mercurial preparations must be dispensed 
with ; the patient placed at rest on the use of the most bland and simple 
nourishment, such as milk, thin wheat flour and milk gruel, oat meal 
gruel, beef tea or other animal broths, in sufficient quantities to sustain 
nutrition, and all attempts to use solid food or articles requiring mastica- 
tion should be avoided. It is better that the bowels be kept in a regular 
condition, either by the mildest laxatives or enemas, while ail drastic ar- 
ticles of physic are worse than useless. 

For ameliorating the condition of the mouth, I have found nothing more 
valuable than a solution of the chlorate of potassium in mucilage of gum 
arabic, with tincture of belladonna added in such proportions that with 
each dessert spoonful of the solution the patient would get from three to 
five decigrams (gr. v-iii) of the chlorate and from one third to one fifth of a 
centimeter (min. iii-v) of the tincture,which quantity may be given profit- 
ably as often in the milder cases as once in six hours, and in those more 
severe every two or three hours, until the symptoms have materially im- 
proved. In those cases in which there is acute glossitis, or inflammation 
and much tumefaction of the tongue, I have thought the iodide of 
potassium given in the same manner and in the same doses as the chlorate 
exerted a more beneficial influence. 

In the later stages of the disease, when patients have become consider- 
ably debilitated, and the ulcerations in the mouth seem disposed to heal 
slowly, an increased amount of nourishment should be given and the use 
of compound tincture of cinchona, or tincture of the chloride of iron, may 
be substituted for the chlorate of potassium or the iodide. For local 
remedies directly to the mouth, weak solutions of carbolic acid or perman- 
ganate of potassium are perhaps the best, particularly in all the earlier 
stages in the progress of the inflammation. When the flow of saliva is 
very profuse I have thought the addition of belladonna to the solutions 



STOMATITIS MATERNI; 4 ( J7 

either of the permanganate or carbolic acid had some effect in lessening this 
flow, and consequently aided in relieving the patient. But it is with 
the same motive, namely, to aid in checking the flow of saliva by its in- 
fluence upon the vaso-motor nerves that I add belladonna to the solutions 
of chlorate of potassium and iodide of potassium, as I have already rec- 
ommended for internal use. When the disease has passed its climax and 
the ulcerations in the mouth are inclined to heal but slowly, or re- 
main stationary, you sometimes derive much advantage from the use of 
local applications of a more stimulating or astringent quality. The infu- 
sion of coptis root and sage leaves, as already mentioned; infusions of the 
geranium maculatum root, or of calamus (sweet flag) root will be found 
among the best, as washes to be applied freely to the whole surface 
of the mouth and fauces three or four times a day. In some rare instances, 
individual ulcers assuming a more indolent form, may be benefited by 
touching them directly with the solid sulphate of copper in the same man- 
ner as mentioned in the treatment of apthous ulcers. 

Stomatitis Materni. — The disease commencing in the mouth designated 
as nursing sore mouth, is peculiar to women during the period of nursing, 
and in some cases during the advanced stage of pregnancy. It appears 
to originate from a deficiency in the relative proportion of some of the 
constituents of the blood needed for maintaining healthy nutrition, 
caused by the separation of too large a proportion of those ingredients for 
the nutrition of the foetus in the latter months of utero-gestation, and still 
more in the milk secreted during the period of nursing. Precisely which 
of the elements of the blood necessary for maintaining nutritive processes 
are deficient, has not been ascertained. Examination with the microscope, 
together with some chemical analyses made by myself several years since, 
led me to the conclusion that there was deficiency both in the chlorine 
and the phosphatic salts in the serum of the blood, and some degree of 
deficiency in the hagmatin, or the particular form of iron necessary for the 
formation of the red corpuscles. But, without attempting to define posi- 
tively the particular change in the condition of the blood which precedes 
and accompanies this form of sore mouth, it is sufficient for our present 
purpose to recognize the well established clinical fact that the disease 
originates and progresses only during the period when there is a drain 
upon the nutritive elements of the mother's blood, of such materials as 
are required to nourish her infant, either in the advanced period of its 
growth before, or during the most rapid period of its development after, 
birth. The great majority of cases of this kind commence in from two to 
eight weeks after the confinement of the mother, and the commencement 
of her nursing. It is not very uncommon, however, for it to commence at 
a later period, and a smaller number not only begin but make con- 
siderable progress during the last two months of pregnancy. 

Symptoms. — The initial symptoms of the disease are usually a feeling of 
heat and tenderness along the edges of the tongue, the inside of the cheeks, 
and a little later, the inside of the lips and the edges of the gums. On ex- 
amining the mouth at a very early period, the parts affected will present 
only a slightly reddened and granular appearance as though the epithelial 
layer of the membrane had been disturbed. A few days later there will 
be very distinct red spots upon the edges of the tongue, sometimes upon 
the interior face of the fauces, inside of the cheeks, varying in size from 
the head of a pin to elevated patches the size of a silver half dime. Usu- 
ally the inflammation thus begun in the membrane of the mouth extends 
pretty rapidly until in a few weeks' time it will occupy the greater part 
of the membrane lining the inside of the cheeks, the lips, edges of 
32 



493 STOMATITIS MATERNI. 

the tongue, and along the gums and fauces. In many, the tonsils become 
slightly swollen as well as the sub-maxillary and sub-lingual glands, caus- 
ing a considerably increased flow of saliva and a constant sense of heat 
or smarting greatly aggravated whenever the patient attempts to take 
either food or drink. In the meantime the general condition of the pa- 
tient shows progressive impoverishment, by a paler countenance, some loss 
of flesh, decided feelings of weakness or weariness on slight exertion, a 
little quickening of the pulse, sometimes headache, and in the earlier 
stages moderate constipation of the bowels. In some instances the pa- 
tients often complain of much dull aching pain and a sense of weariness, 
especially in the lower extremities during the latter part of the afternoon 
and evening, with slight elevation of the temperature above the natural 
standard. The more inflamed patches of the membrane lining the mouth 
gradually soften and disintegrate, presenting appearances of irregular su- 
perficial ulcerations. The saliva and breath become more or less offen- 
sive. 

In man} 7- cases the disease extends slowly but steadily backward over 
the pharynx, adding difficulty and pain in deglutition, and sooner or 
later attacking the membrane lining the stomach. Its invasion of the 
gastric mucous membrane is marked by feelings of heat, or burning in the 
stomach, greatly aggravated whenever the patient takes food, and after 
making progress for one or two weeks, destroys the appetite and prompts 
the patient to frequently reject by vomiting even the blandest articles of 
nourishment. The patient, now being able to take and retain but a 
very small amount of nourishment, becomes much more rapidly impover- 
ished than while the disease was confined to the mouth and fauces. If no 
measures are taken to counteract the progress of the disease, evidences of 
inflamed patches of the mucous membrane of the ilium are added to those 
of the stomach. Sensations of more or less heat or burning, and occasion- 
ally griping pains, are felt in the abdomen, with increased peristaltic 
motion, and now, instead of a tendency to constipation the bowels become 
loose, often giving rise to from four to six or eight thin reddish brown pas- 
sages every twentv-four hours. The disease, having thus invaded a 
large portion of the mucous membrane of the mouth, stomach, duodenum, 
and lower half of the small intestine, deprives the patient of the ability to 
either receive or digest nourishment on the one hand, and to undergo 
sufficiently active wasting from the diarrhoea on the other, to cause so much 
emaciation and loss of strength as to compel her to take her bed. And if 
the nursing process is continued, the disease and exhaustion progress 
with steadily increasing rapidity until the destruction of a large portion 
of the mucous membrane of the alimentary canal has taken place, when 
the discharges become involuntary, the urinary secretion nearly sup- 
pressed, and the patient dies from asthenia, or exhaustion. Such is the 
clinical history of severe cases of this form of disease, when it is allowed 
to take its own course uncontrolled by appropriate treatment, or bv- the re- 
moval of its cause. But there are very many milder cases in which the 
inflammation is limited during the whole period of its progress to the 
membrane of the mouth and fauces causing the mother much inconven- 
ience and suffering, and yet not destroying her ability to maintain 
sufficient nutrition to go through the ordinary period of nursing, at least 
nine or twelve months, and on the cessation of this process by w T eauing 
of the child, the mouth speedily heals and her usual health is restored. 

There are many other cases of considerable severity, in which the 
mother, by the use of appropriate remedies and diet, and the addition of 
good hygienic surroundings, may so far control the progress of the disease 



TREATMENT. 499 

as to secure entire relief and continue her nursing. In many cases, 
however, the best treatment will only hold the disease so far in abeyance 
that the suffering amounts to no more than an uncomfortable tenderness 
and feeling of heat in the mouth, increased while taking food, but not 
interfering with the process of nutrition sufficient to prevent her from 
continuing the duties of her household throughout the whole period usu- 
ally allotted to nursing. My attention was first strongly directed to 
this form of disease nearly forty years since. I then studied a few cases 
with much care, watching closely the influence of different remedial 
agents, and also chemically and microscopically examining the composi- 
tion of the blood, until I became satisfied that the elements chiefly ex- 
hausted, or reduced to too small a proportion for the proper nutrition of 
the mother, were the phosphatic compounds, and perhaps in a less degree 
the chlorine salts. Becoming satisfied of the general correctness of this 
conclusion T have since treated all the cases that have come directly un- 
der my own care, mainly, with the view of increasing the amount of these 
agents in the blood, and the result has been entirely satisfactory. 

Treatment. — At the period of time to which I allude, a case of the dis- 
ease occurred in my own family. As it was very desirable to 
avoid taking the child from the mother's breast, I procured as emi- 
nent counsel as could be obtained then in the city of New York, 
and the patient was treated for four months with the best diet and wmat 
was deemed the most efficient tonics, including the various preparations 
of iron, quinine, the different preparations of cinchona and other bitter 
tonics, aided by the liberal use of milk-punch, egg-nog, and all the class 
of agents supposed to be capable of sustaining strength and promoting 
nutrition. But the disease steadily increased, apparently being in no 
sense controlled or modified by the treatment adopted, until at the end 
of the four months the mother had become so much reduced, that it 
was deemed no longer safe to allow nursing to proceed; and consequently 
the child was removed from her breasts. The further secretion of milk 
soon ceased and was followed directly by indications of improvement in 
the condition of the mouth and stomach, and in a few weeks without any 
other remedial influences the mother had recovered. It was the unsatis- 
factory result of the treatment in this case that led to the further study 
of the pathological condition of the blood to which I have already al- 
luded. Acting upon the hints gained in that study, I commenced in 
all the subsequent cases that came under my observation in their early 
stage, while the mouth was simply tender and burning with only slight 
patches of redness in it, to give internally four cubic centimeters of the 
compound syrup of the hypophosphites, or the same quantity of the 
syrup of the lacto-phosphate of calcium, immediately after each meal. 

The patients have been allowed to take no stimulants, no preparation of 
iron, but the simpler and more easily digestible articles of food, being 
careful that they had, as far as practicable, access each day to some out- 
side air by riding, or at least sitting in the sunshine outside the door. 
When the use of these remedies was begun thus early they invariably 
checked the progress of the disease. And although I have seen many of 
these cases within the last thirty-five years, in no instance where the rem- 
edies have continued to be used steadily with proper attention to diet 
and good air, have the patients failed to so far keep the disease in check 
as to be able, with only a very moderate degree of inconvenience, to go 
through the ordinary period of nursing. The same mother whose case 
proved so obstinate that the child had to be weaned after the fourth 
month, in two subsequent pregnancies began to exhibit the incipient 



OKJKJ STOMATITIS MATERXI. 

stage of sore mouth about the end of the eighth month of each, and it 
slowly increased through the remaining month to the time of confine- 
ment. The commencement of the process of nursing was almost immedi- 
ately attended by an increase of these manifestations of soreness in the 
mouth, bringing the disease to a degree of development that was unmis- 
takable, when a resort to the use of the remedies I have just named soon 
arrested its further progress, and so long as they were faithfully used at 
each meal-time, the disease was held so far in abeyance as to leave at 
times no feelings of inconvenience in the mouth. But if, as happened 
several times during the progress of the period of nursing, the mother 
feeling but little inconvenience and weary with the daily taking of medi- 
cine, neglected it for one week, the symptoms of inflammation were 
again plainly manifested. The resumption of their use was followed 
again by the usual degree of relief. It appears to me that these cases, 
together with others that I had the most favorable opportunity to watch, 
furnish as perfect a demonstration of the efficacy of these remedial agents, 
in supplying the needed materials to the blood, and in consequence either 
entirely arresting or ameliorating the disease, as we could get by any 
process of experimentation on the use of remedies. But, it is only when 
the treatment has been commenced, in the early stages of the disease, 
more particularly before it has invaded the membrane lining the stom- 
ach, or produced very extensive ulceration in the fauces, that it is certain 
to arrest its progress. If the use of the remedies is delayed until the dis- 
ease has made considerable advancement, and especially after it has in- 
vaded the membrane of the stomach, producing a tendency to reject food 
and sometimes the medicine itself, the patient will continue to lose flesh 
and strength and the disease will continue to extend until it occupies the 
whole of the mucous membrane. 

There are other remedies, however, besides those I have named, that 
are regarded as producing some beneficial effect, and I am quite sure, 
when the patients are living in a highly malarious district, the use of 
quinine in moderate doses will aid materially in retarding or arresting 
the disease. Chlorate of potassium is also a remedy which has been used 
with a considerable degree of success. Some writers speak confidently of 
the efficacy of large doses of the chlorate of potassium, ten to fifteen deci- 
grams (gr. xv to xxv) three times a day. I have not used this remedy 
in such large doses, but I have given many patients a solution of the 
chlorate of potassium in mucilage of gum arabic in doses of from two to 
three decigrams (gr. iii to v) three times a day with decided advan- 
tage. A weak solution of chlorate of potassium and belladonna may be 
used as a wash for the mouth and gargle for the throat three or four times 
a day also with benefit. Another excellent wash and gargle, especially 
after the disease has progressed to superficial ulceration, is the infusion 
of coptis or gold-thread root, sage leaves and a little borate of sodium, 
prepared as I have previously mentioned in the treatment of another form 
of sore mouth. The burning in the mouth will be much alleviated in 
most cases by allowing the patient to take frequently and plentifully 
of cold mucilaginous fluid, such as solutions of gum arabic, slippery elm 
or comfrey root. 

They may be made more cold b} r placing in them lumps of ice. When- 
ever the disease has progressed so far, before coming under treatment, as 
to invade the mucous membrane of the stomach, or any part of the ali- 
mentary canal, making it difficult for the patient to retain food, or causing 
more or less wasting diarrhoea, it is not proper to subject the patient to 
the further risk of losing her health and, perhaps, ultimately her life, by 



SCORBUTIC STOMATITIS. 501 

continuing the process of nursing. But the child should be taken from 
the breast and provided for in some other proper way, a good healthy wet 
nurse being altogether the best when it is practicable, and the mother re- 
lieved from further drain occasioned by the secretion of milk. If this is 
done, and at the same time the remedies I have recommended, together 
with a simple diet consisting largely of wheat flour and milk gruel, or oat- 
meal gruel, are perseveringly used, it rarely happens that improvement 
does not commence within a week and progress rapidly until the patient's 
recovery is complete. Only one exception to this remark has come under 
my notice during the whole period of my practice. It was that of a young 
mother who had the symptoms of the disease developed before the end of 
the first month after she commenced nursing. She obtained but little 
treatment of any kind during the next three or four months, until the dis- 
ease had rendered the whole mouth and fauces excessively sore, and the 
mucous membrane of the stomach so far involved that very little food or 
drink would be retained long enough for absorption, but would occasion 
severe distress during the little period of tiire it was retained. Still neg- 
lecting to remove the child from the breast ci'ter another month, diarrhoea 
commenced, and the symptoms of inflammation and ulceration of the mu- 
cous membrane of the ilium and parts of the colon supervened, with very 
rapid exhaustion of flesh and strength. Although at this late period of 
time the nursing was stopped, yet the patient continued to have a wasting 
diarrhoea, and in the next six months reached the stage of fatal exhaus- 
tion. I saw her only in consultation, perhaps six weeks before her deaths 

Scorbutic Sto?natitis. — Another affection of the mouth which will re- 
quire a few words of comment is that form of inflammation which exists 
in connection with a scorbutic condition of the system. Scurvy, as you 
are aware, originates from a defect in the supply of food; such defect 
usually consisting in the absence of a proper proportion of vegetables 
containing the ordinary fresh vegetable juices and saline matters, until 
these elements become deficient in the whole mass of the blood. Among 
the evidences of general impairment of nutrition in such cases, we have 
early the appearance of a swollen, reddened and sensitive condition of the 
gums around the teeth, and to some extent also of the lining membrane 
of the inside of the cheeks, and over the anterior face of the fauces. The 
gums, particularly, are swollen, tender, and bleed on the slightest touch. 
And as the disease advances the inflammation follows the periosteal mem- 
brane into the sockets of the teeth, causing them to become loose, some- 
times to the extent of falling out spontaneously, the gums become ulcer- 
ated, with patches of ulceration all along the inside of the cheeks, portions 
of the fauces about the junction of the jaws, and sometimes the inner 
surface of the lips. There is much general debility, dullness of the pa- 
tient's sensibilities; in many cases petechial spots on the cutaneous surface, 
slight hemorrhages in the areolar tissues, and very frequent oozing of 
blood both from the gums and the nostrils. 

If the disease is allowed to progress, the patient is apt to exhibit an 
cedematous condition of the feet, ankles and sometimes backs of the hands. 
Often the face about the eyes looks puffy and bloated, the urinary se- 
cretion becomes scanty, general dropsical infiltration of the tissues super- 
venes and not infrequently diarrhoea, hemorrhages from the bowels, some- 
times vomiting of blood, ultimately complete exhaustion, collapse and 
death of the patient takes place. This is not the place, however, to discuss 
the general subject of scorbutic disease, but only so far as it tends to in- 
duce inflammation in the mouth. You will sometimes meet with these 
cases of scorbutic inflammation in the mouth where you would not suspect 
them. 



502 SCORBUTIC STOMATITIS. 

It has been my fortune several times during my residence here in 
Chicago to meet with well marked cases of this disease in the poorer class 
of families living in bad sanitary surroundings, during the middle and lat- 
ter part of winter when fresh vegetables were too expensive for their use, 
causing them to live almost entirely upon salted meat, bread and tea. In 
two or three different seasons when there has been special scarcity of 
fresh vegetables in the market, the children in one of the orphan asylums 
were almost all found to be affected with well-marked scorbutic inflamma- 
tion of the mouth and gums; and some of them with characteristic pete- 
chial spots on the surface, swelling of the feet, ankles, wrists, backs of the 
hands and rheumatic pains to such an extent as to be rendered entirely 
helpless. I recollect, many years ago, one of the most active and eminent 
members of the State Medical Society (Illinois) called the attention of 
the society, at one of its meetings, to the fact that in the open prairie 
country in the central part of the State, he had found well-marked devel- 
opments of scorbutic disease in the families of well-to-do farmers living 
without the use of fresh vegetables during almost the entire winter and 
early spring. For as he very correctly remarked, at that period of time 
many farmers in Illinois who possessed hundreds of acres of rich prairie 
lands, and sold thousands of dollars' worth of cattle and grain in the mar- 
ket would not take the trouble to raise an ordinary supply of garden vege- 
tables for their own use. 

The essential treatment for this variety of sore mouth consists in sup- 
plying the patient with bland nutritious food, embracing a sufficient 
amount of fresh vegetable ingredients. The use of good potatoes is often 
efficient when present in sufficient quantities in the market. Almost 
any of those vegetables that contain plenty of the vegetable acids may 
be used, if they are palatable to the patient. In one of the orphan asy- 
lums to which I alluded, in a season when not less than twenty or thirty 
had become severely affected before any medical aid had been called for, 
fresh, tender rhubarb stems or pie plant, stewed, with the addition of a 
little sugar, making a pleasant tart sauce, was given to all of them, very 
much to the gratification of their tastes, and certainly affording much 
aid in their recovery. In addition to the supply of proper nourishment, 
good air, and cleanliness, the three things most essential in the treatment, 
some good can be obtained by the use of antiseptic and slightly astrin- 
gent washes; perhaps among the best is a solution of permanganate of 
potassium, of the strength of two or three decigrams (gr. iii or v) to 
sixty cubic centimeters (|ii) of water, with which the mouth may be 
rinsed from three to four times a day. 

Another excellent wash for local effect upon the mouth consists of car- 
bolic acid and sulphate of zinc, each three decigrams (gr. v), pure 
glycerine, ten cubic centimeters (fl. 3iiss) with a hundred and seventy- 
five cubic centimeters (fl. §vss) of water. Some advantage may also be ob- 
tained by the administration internally of the compound syrup of the 
hypophosphites acidulated with phosphoric acid sufficient to give it a 
slightly tart taste; and perhaps still better the syrup of the lacto-phos- 
phate of calcium, and a small amount of the sulphate of quinine or some of 
the more palatable preparations of peruvian bark. If diarrhoea exists it 
should be controlled by the very cautious use of anodynes, of which, if 
the stomach will retain it, small doses of the compound powder of opium 
and ipecacuanha will be preferable. If this is not well borne by the 
stomach, small doses of carbolic acid in solution with camphorated tinc- 
ture of opium may be given as a substitute, the dose of the two ingredi- 
ents being duly proportioned to the age of the patient. 



GANGRENOUS SORE MOUTH. 503 

Gangrenous Sore Mouth. — Another inflammatory affection of the 
mouth sometimes though rarely met with, is what I shall denominate 
gangrenous inflammation. This appears in two forms. One, of which I 
have seen only a few cases, is limited almost entirely to the gums. It at- 
tacks the thin edge of the gums, causing that edge to the depth of a sin- 
gle line to turn an ash gray color, become shriveled, and in three or four 
days to separate from the living part, leaving the latter raw, and trun- 
cated in appearance. But in a case that came under my observation, in 
three or four days after the separation of the first slough, another layer 
appeared to suffer death in the same way, and go through the same proc- 
ess of withering, separating and leaving a still deeper degree of ulceration 
and truncation of the remaining gums. Another of these cases of disease 
seemed to attack, first, only the gums around two or three of the front teeth 
and extending directly from them backward, attacked the gums successive- 
ly until all or nearly all of the gums in the mouth had undergone the same 
change. Cases of this variety have been known to extend from the gums 
to the alveolar process, until the teeth have been loosened and removed 
from their sockets, the jaw denuded of its flesh and the bone itself affected 
with caries. The disease extends finally to the cheeks, inducing a degree 
of phagedenic ulceration, which soon destroys all the soft parts, leaving an 
open door to the mouth through which the saliva is constantly drooling. 
This causes rapid wasting of the patient like one suffering from some 
malignant form of disease, feuch instances generally end fatally. 
When disease thus assumes a phagedenic ulcerative character, and des- 
troys the cheeks and soft parts of the mouth, it has been denominated by 
most writers, cancrum oris. But this latter disease by no means always 
commences with gangrene of the gums. It not infrequently has its be- 
ginning in small irritable ulcers upon the inside of the cheeks which 
extend rapidly in all directions until they produce the extent of de- 
struction I have already alluded to. In most of the cases that have come 
under my observation the disease has been limited to the gums. Two 
of them recovered under constitutional treatment, combining tonics with 
mild alteratives, and the use of local astringents and slightly stimulating 
washes. 

One of them, however, persisted until the safety of the teeth and gums 
was threatened. The patient being an inveterate user of tobacco, he 
was persuaded to discontinue its use. Within a week after the discon- 
tinuance of the tobacco the gums began to improve, and continued to do 
so until recovery was complete. After getting entirety well and remaining 
so for three or four months, the patient began again his old habit of using 
tobacco, gradually increasing it until he had returned nearly to his former 
excessive use, when to his surprise the disease again attacked his gums. 
On omitting his tobacco recovery soon took place; and after going without 
it for a year he resumed his old habit, which was again followed by a re- 
turn of the disease in his gums and mouth. 

I think all the patients I have seen with this form of gangrene have 
been users of tobacco; and yet it would be unfair to assume that it was 
the chief cause of this disease. That the use of this agent is the chief 
cause of many chronic affections of the mucous membrane of the mouth 
and fauces, and that it tends to perpetuate or prevent the cure of many 
more having their origin in some other cause, I have no doubt. The 
treatment of this form of gangrenous and ulcerative sore mouth consists 
in the use of tonics internally, and the discontinuance of all habits that 
may have an injurious influence upon the patient; mild and nutritious diet, 
and the local application, first, of slightly stimulating washes. If no fa- 



504: GANGRENOUS SORE MOUTH. 

vorable impression is made, one or two applications of a strong solution 
of the chloride of zinc, or of the concentrated carbolic acid will usually 
60 far change the morbid action that the subsequent use of milder astrin- 
gent washes will be sufficient to arrest the disease. Some of the cases, 
called cancrum oris, or eating ulceration, occurring chiefly in children, 
are more malignant, and persist in their destructive progress in opposition 
to all remedies. The other form of gangrenous inflammation of the mouth 
to which 1 alluded, occurs usually in connection with some one of the 
acute general diseases, either during the last part of their progress or in 
the early stage of convalescence. The only cases I have seen occurred 
in connection with typhoid fever and small-pox. The first symptom of 
the disease is usually the appearance of a pale, ash-gray colored spot on 
the inside of the lip, or of the cheek, accompanied by considerable tu- 
mefaction from exudation into the subjacent connective tissue. 

Before opening the mouth you will observe the lip or the cheek, as 
the case may be, to be swollen exteriorly, the skin a little paler than nat- 
ural, smooth or shining in appearance. Placing your finger upon the 
surface you find it more dense or harder than natural. Examining the in- 
terior surface, you will find a prominent spot of the size usually of a half 
dime, the central portion of which presents a pale ash-gray color with a 
dark areola around its margin. The patient complains very little of pain 
or any kind of unpleasant sensation, except the feelings of stiffness or in- 
convenience in the motions of the mouth. 

The swelling as I have described usually appears suddenly. In from 
twenty-four to forty-eight hours after its commencement, this central pale 
spot on the interior of the swollen part will have turned brown and more 
corrugated, presenting distinctly the appearance of a gangrenous slough. 
Sometimes the gangrene extends only through the mucous membrane, 
or a little way into the subjacent areolar tissue. The separation takes 
place at the line of the areola of redness, and in four or five days the 
dead tissue becomes loose, and is removed, leaving an open ulcer with a 
non-granulating surface resting upon a rather hard base. In other cases 
it extends through the whole depth of the tissues to the exterior. In the 
more superficial cases due attention to the patient's general condition, 
with mild soothing applications to the ulcer, will cause granulations to 
spring up, and in a brief time cicatrization is completed without resulting 
deformity. When the separation of the slough leaves an opening direct- 
ly through the cheek or a portion of the lip, leaving a gap through which 
saliva drools from the mouth, and renders it difficult for the patient to 
take his food, much care is required in the local management, both for 
the purpose of aiding the retention of the saliva and in so directing the 
progress of repair as to make the resulting deformity as little as possible. 
One of the most marked cases that have come under my observation 
occurred in connection with a case of confluent small-pox many years 
since. The patient, a woman at the head of a family, was attacked with 
the initial symptoms of small-pox simultaneously with her confinement; 
the pustules of the small- pox began to show upon her face in twenty-four 
hours after her delivery; and its development proved severely confluent. 
She became much enfeebled, and just at the completion of the suppura- 
tive stage of the eruption, gangrene attacked the inner side of one 
cheek, resulting in destruction of the whole of the tissues and 
leaving an opening exteriorly at least six lines in diameter. The pa- 
tient, however, survived, and during convalescence, by keeping the open- 
ing exteriorly so covered as to prevent the contents of the mouth from 
coming through, it gradually filled up by granulations on the edges and 



GLOSSITIS. 505 

by fin occasional application of nitrate of silver, the process was continued 
until it ultimately closed the whole opening, leaving only a depressed and 
unseemly scar in the center of the cheek. Another case occurred in a 
boy who suffered a long time from angular curvature of the spine, and 
in addition a severe attack of typhoid fever. Just as convalescence had 
fairly begun from the fever, this form of gangrene attacked the inside 
of the lower lip about midway between the center of the lip and the an- 
gle of the mouth. It resulted in the death of the entire thickness of the 
lip, and separation as a gangrenous slough, from the median line of the 
incisor teeth to a little beyond the angle of the mouth and down to the 
junction of the lip with the jaw, taking out the entire left half of the 
lower lip. 

Convalescence, however, was not interrupted and after the recovery was 
complete and as good a condition of general health restored as he was 
capable of having with his old angular curvature of the spine, there was 
left a large gap through which the saliva and the liquids taken into the 
mouth freely escaped. My colleague in the chair of clinical surgery, Dr. 
Edmund Andrews, at my request then performed an operation somewhat 
similar to that for hare- lip, which resulted in restoring the continuity of 
the parts, and remedying all the inconveniences the patient had suf- 
fered except a straight seam where the edges of the lip were united. 
The lower lip appeared shorter than the upper. I know of no treat- 
ment that is required for this form of gangrene in the mouth except 
that which is needed by the general condition of the patient, and the use 
of such antiseptic applications as will destroy the formation of septic ma- 
terial, and the olfensiveness of the odor during the separation of the 
gangrenous parts from the living. And after such separation to so treat 
the gaps that may be lefc as to leave the least deformity on the completion 
of the patient's recovery. 



LECTURE LI. 



Inflammations of the Organs of Digestion, continued— Glossitis, Tonsilitis, etc.; their Symptoms, 
Diagnosis, Prognosis and Treatment. 

GENTLEMEN : By glossitis is meant inflammation of the muscular 
structure and connective tissue of the tongue ; and except in con- 
nection with mercurial salivation, of which I have already spoken, 
it is of rare occurrence. The action of some of the corrosive poisons 
when taken into the mouth, and attempted to be swallowed, extends 
to the substance of the tongue and causes severe glossitis. Occasion- 
ally a case of inflammation involving the tonsils, fauces and tongue 
will be met with in the same patient, occurring idiopathically or 
without any known cause. Within the last three days I have 
seen two cases of this kind in which inflammation of an acute grade 
attacked the tonsils and extended rapidly over the whole fauces and to 
the root and back part of the tongue. The inflammation steadily increased 
for about three or four days from the commencement of the attack, when, 



50G GLOSSITIS. 

in both instances, the tongue was sufficiently swollen to make it difficult 
for the patient to retain it inside the mouth ; causing the jaws to be kept 
open and the tongue to protrude between the teeth. At the same time 
three or four other children in the same family had different degrees of 
inflammation of the fauces and tonsils, when one of them presented a 
diffuse red exanthematous rash of moderate extent, much resembling the 
rash of scarlatina. But in neither those having glossitis, nor those having 
simple sore throat, did their symptoms correspond with scarlet fever, 
nor did they show any appearance of diphtheritic exudation upon 
the surface of the tonsils. The disease ran a brief course reaching its 
climax in about four or five days, then declined until convalescence was 
reached at the end of the seventh day. Such cases as involve the fauces 
are of frequent occurrence during the transition seasons — fall and spring, 
but extension of the inflammation to the tongue is quite uncommon. The 
symptoms of glossitis are pain, usually of a dull character, referred to the 
region of the larynx and roots of the tongue, much swelling or enlarge- 
ment usually of the whole body of the tongue, though sometimes it is 
limited more to the back part, at others to one half of the tongue longi- 
tudinally. The degree of swelling varies much in different cases, from a 
moderate degree of enlargement, the tongue may swell so as to fill up the 
whole mouth, protrude beyond the teeth and render it almost impossible 
far the patients to perform the act of deglutition. After the first twenty- 
four hours there is usually an increased flow of saliva, either dribbling 
from the mouth when the tongue protrudes or accumulating in the fauces 
giving the patient more or less difficulty and pain in dislodging it. 

The pulse is usually moderately accelerated in frequency and increased 
in force, with slight general increase of temperature. In most cases there 
is some degree of headache, especially in the frontal region, and a very 
unpleasant feeling of fullness and obstruction in the fauces. Sometimes 
the disease has been known to be protracted a week, and finally termi- 
nated in suppuration, forming circumscribed abcesses in the tongue itself. 
Far more frequently, however, the inflammation reaches its climax in from 
three to five days, and then gradually declines and disappears by resolu- 
tion, without suppuration. I have noticed it much more frequently in 
young persons between the ages of five and fifteen years, than either at 
an earlier or later period of lile. 

When the disease is of a moderate degree of intensity, it is sufficient to 
keep the patients at rest, giving them bland, simple nourishment, opening 
the bowels moderately by a saline laxative, after which from two to three 
decigrams (gr. iii to v) of iodide of potassium in solution with the 
same number of minims of tincture of belladonna may be given every 
three or four hours until the inflammation abates and the tongue returns 
more nearly to its natural condition. When the saliva is very viscid and 
difficult to dislodge from the back part of the mouth, rinsing out the mouth 
freely with slightly acidulated gargles, such as a weak solution of chlorate . 
of potassium, rendered very slightly acid by a few drops of hydrochloric 
acid, will often much relieve the patient. In cases more acute and severe 
in their character, leading to rapid swelling of the tongue, sufficient to 
threaten much obstruction to deglutition, and greater or less obstruc- 
tion to breathing, an application of leeches directly along the side of the 
pharynx under the angle of the jaw, the number being adapted to the age 
of the patient, thereby producing free local bleeding, will be of much 
advantage. In the two recent cases to which I alluded the particu- 
lar remedies used were a solution of the chlorate of potassium with 
tincture of belladonna in the proportion just named, given every four 



TONSILITIS. 507 

hours, and three decigrams (gr. v) of the salicylate of sodium, in solu- 
tion, between. 

Tonsilitis. — Inflammation of the tonsils to which I next call your atten- 
tion, is very much more frequent in its occurrence than any form of glos- 
sitis. It occurs chiefly during the cold seasons of the year, especially 
during cold, wet and changeable weather, and occurs much more fre- 
quently during the period of early adult life than later. Some patients 
acquire such a degree of susceptibility to inflammation of the tonsils, that 
they suffer an attack from one to three times almost every year; more 
frequently in the early spring months, but sometimes both in the latter 
part of the fall and the spring. Inflammation attacking these glands may 
be met with of almost every degree of intensity, from a purely chronic 
grade, to that of the most acute and severe. The symptoms which char- 
acterize the beginning of the acute and subacute attacks are usually a 
brief period of chilliness, with more or less aching in the back and limbs, 
sometimes in the head, followed by a moderate degree of general fever. 
It causes acceleration of pulse, ranging from ninety to ninety-five per min- 
ute, dryness and heat of the skin, slight degree of thirst and frequently a 
thin white coat upon the tongue. In most instances the urinary secretion 
is redder than natural and scanty. Among these early symptoms, coinci- 
dent with moderate feelings of chilliness, is a sense of soreness and full- 
ness in the fauces, causing sharp pain in deglutition, and often sending 
sharp pains in the direction of the middle ear. On looking into the fau- 
ces the tonsils are seen to be swollen, one or both of them, forming rounded 
projections on each side of the arch of the fauces between the folds of the 
palate, having an intensely red appearance, at first rather dryer than nat- 
ural, but before the end of the first twenty-four hours, accompanied by an 
increased secretion of viscid saliva. In acute cases the swelling and red 
ness increase with considerable rapidity for about three days; at the end 
of which time the patient finds it extremely difficult to perform the act of 
deglutition, the effort causing very acute pain both in the fauces and in 
the direction of the ears; the respiration is moderately obstructed more by 
the collection of viscid mucus than by the actual narrowing of the passage 
of the larynx; a great sense of fullness and obstruction, sometimes creating 
a feeling of suffocation is experienced. There is much frontal headache, 
marked acceleration of pulse, and in many cases a feeling that the patient 
can not take the recumbent position, but must lean forward to let the 
saliva " drool" from the mouth, or be turned to one side so that it will 
not gravitate back into the fauces. In the most acute class of cases, such 
as are met with only occasionally, with both tonsils involved at the same 
time, the swelling becomes so great that the glands touch each other in 
the center, crowding the uvula in front of them, and so narrowing the 
passage over the root of the tongue as to produce really much obstruction 
to respiration, preventing the patient from assuming the recumbent posi- 
tion altogether, so far interfering with the oxygenation and decarboniza- 
tion of the blood as to give a leaden hue to the countenance, purplish 
appearance under the nails and lips, coldness of the extremities, small, 
thready, weak pulse, with disposition to drowsiness; and yet inability to 
continue sleep more than a few seconds on account of feelings of suffoca- 
tion, making an assemblage of symptoms decidedly alarming, and if not 
speedily relieved they might result in the actual death of the patient. 

But in nearly all the cases that have come under my own observation, 
the arrival of this stage, with the symptoms just named, has been accom- 
panied by suppuration, or the maturing of an abscess in the tonsil, which if 
not opened by a free incision has broken spontaneously during some 



508 TONSILITIS. 

severe effort of the patient to clear his throat, and on the discharge of the 
pus by either process, the relief to the more distressing symptoms has 
been so speedy and complete, that in less than an hour the patient has 
been resting in a horizontal position in a quiet comfortable sleep. The 
rapidity of improvement after acute tonsilitis has terminated in suppura- 
tion and discharge of pus is remarkable. I have seen many patients that 
thought they were in danger of suffocation, who by having the abscess 
opened freely, were up and dressed the next day, declaring that they were 
quite well. In the more acute form of tonsilitis there is a decided ten- 
dency to suppuration ; so much so that if the disease is not promptly met 
by means strongly calculated to check the inflammatory process in its 
incipiency, the majority of cases will proceed to suppuration in spite of 
any subsequent treatment. The cases of a subacute character will often 
proceed very slowly, accompanied by symptoms of a milder character, 
reaching their climax at the end of five or six days, and then very 
gradually declining by resolution or return to their normal condition. 
Where patients are attacked with subacute tonsilitis once or twice a 
year, there is usually a tendency to hypertrophy or permanent enlargement 
of the glands. In children especially who have been a few times attacked 
with mild subacute inflammation of the tonsils from ordinary colds, the 
exudation appears to be sufficiently plastic to become incorporated with 
the natural structure of the gland, and to remain, giving them a size two, 
three or four times as large as natural, projecting as rounded or convex 
bodies into the opening of the fauces, crowding sometimes against the 
opening of the Eustachian tube so as to interfere with the passage of air 
to the middle ear, sometimes causing buzzing and noises in the ear, at 
other times slight impairment of hearing. There is still a lower grade of 
inflammatory action which appears often in the tonsils of children more 
frequently between the ages of five and eight years, not active enough to 
cause acute soreness, pain or fever at any time, but causing a little sore- 
ness for a few days on taking what is called a cold by exposure to cold 
and damp air, and leading to a steady increased growth of the connective 
tissue constituting sclerosis or hardening of the substance of the gland until 
it acquires the size of a hickory nut, impairing the tone of voice and often 
causing sufficient obstruction, so that when the patient sleeps it renders 
the sleep noisy or stertorous. Frequently the patient starts out of his 
sleep as if from fright. This often causes both parents and friends to be 
unduly anxious, fearing that some serious obstruction in the respiratory 
passages exists. But during it all, the patient complains very little from 
this hypertrophy of the tonsils. 

Chronic enlargement of the tonsils almost always increases during the 
cold season of the year, and sometimes occasions impairment of hearing 
in some degree, while during the warm season it recedes sufficiently 
to relieve all the prominent symptoms, yet does not entirely disap- 
pear. Tonsilitis of any grade of intensity very rarely proves fatal. No 
such case has come under my own observation during all the years of my 
experience. I have met with several which, at the climax or period of 
maturity of the suppurative process, presented such symptoms as I have 
described, and caused a just apprehension that suffocation would take 
place if relief was not obtained by some means, speedily. In all such in- 
stances I have proceeded at once to make a free incision into the most 
prominent part of each tonsil, and have not failed to procure a free dis- 
charge of matter, and a speedy relief to all the more urgent symptoms. 
The treatment of acute and subacute tonsilitis, when they come under 
the care of the physician in the incipient or early stage of the disease, 



TREATMENT. 509 

may have for its object either an entire arrest of the disease by rendering 
the inflammatory process abortive, or simply to so moderate it as to avoid 
extreme distress and danger to the patient, until it had run more nearly 
its natural course to spontaneous recovery. For the first object, if the 
attack lias been ushered in by a decided chill, such rapid development of 
swelling, pain and feverishness as to indicate a very acute form of the 
disease, an immediate application of five or six leeches to the neck directly 
opposite the tonsils, on each side, if the patient is an adult; a proportion- 
ately smaller number in children, may be made, and the bleeding encour- 
aged by cloths wet in warm water after the leeches fall off, and as soon as 
it has ceased, the neck opposite the tonsils should be kept constantly 
covered with cloths wet in infusion of aconite leaves in which is dissolved 
muriate of ammonium. Internally, as early as possible, from four to six 
decigrams (gr. vi to x) each of the compound powder of opium and 
ipecacuanha and the sulphate of quinia may be given, and the same to be re- 
peated if the patient does not fall asleep, and show some moisture of 
the skin, in four hours. There are some cases even of a very acute form, 
in which prompt local bleeding by leeches, the enveloping of the neck 
in cloths wet in some anodyne infusion, externally, and one or two full 
doses of the quinine and compound powder of ipecacuanha will be followed 
by a few hours of sleep, during which the patient sweats freely, the pulse 
returns to the natural standard, and the soreness that had rapidly com- 
menced in the fauces, with almost equal rapidity declines. After the 
patient has finished his sleep the exhibition of a saline laxative sufficient 
to move the boweis moderately during the day, and another anodyne and 
diaphoretic powder the following night, will complete the resolution or 
arrest of the inflammatory process, the patient recovering with little or no 
other treatment. Cases of a less degree of severity, when coming under 
the care of the physician directly after the initial symptoms have com- 
menced, may be rendered abortive by the same treatment without the use 
of the leeches or local bleeding. 

But if this first stage of acute or subacute cases has passed by, and 
forty-eight hours have elapsed before they come under the observation of 
the physician, according to my experience, it is useless to attempt to 
abort the disease. The aim should then be simply to lessen the more 
distressing symptoms of the patient, by opening the bowels moderately if 
they are costive, allowing the patient to either gargle his throat, or 
swallow a weak solution of chlorate of potassium in which is placed a 
small proportion of belladonna every two hours, so as to bring the remedy in 
contact with the throat frequently. If there be considerable headache, 
dry skin, moderately full pulse, taking from six to eight decigrams of 
the salicylate of sodium dissolved in water every four hours, will act as 
an anti-pyretic and very much relieve all the symptoms most trouble- 
some to the patient. Externally, cloths may be applied over the region 
of the tonsils, wet in the same infusion I have already mentioned. In the 
milder cases under the influence of these remedies the inflammation of the 
tonsils will usually reach its climax in from three to five days, and begin 
to decline, and disappear altogether in from seven to ten days. In the 
more severe cases suppuration will take place and the symptoms will 
gradually increase in severity in all respects until the suppurative 
process has matured and the abscesses are either opened, or break spon- 
taneously, which in most cases will be between the fifth and seventh days 
from the commencement of the attack. Occasionally the process may be 
protracted to a later period. After this, in most cases very little treat- 
ment is required, the patient rapidly recovering. If there should be much 



510 OESOPHAGITIS. 

debility, loss of appetite, and inclination to night sweats, the patient will 
be benefited by taking moderate doses of quinine and iron three times a 
day, until the period of convalescence is passed. You will occasionally 
meet with cases of subacute tonsilitis, in which after the first week the 
more acute symptoms disappear but the tonsils remain large, redder than 
natural and sufficiently tender to cause some pain in deglutition, interfering 
much with the patient's comfort in eating and drinking, and subjecting 
him to a disagreeable sense of fullness in the fauces, with more than the 
natural secretion of viscid mucus. 

In such cases I have found three decigrams (gr. v) doses of the 
iodide of potassium given four times a day to cause a more rapid decline 
in the enlargement of the tonsils and an earlier recovery of the patient. 
In these cases also, if the patient has resided in a malarious district, and 
presents a more or less anaemic hue, with a sense of lassitude, from two to 
three decigrams (gr. iii to v) of quinine morning and evening in ad- 
dition to the iodide of potassium, may be given with advantage. When 
the tonsils have become permanently hypertrophied or enlarged, sufficient 
either to disagreeably obstruct the fauces, or interfere with the Eustachian 
tube, and render the sleep of the patient disturbed and uncomfortable, the 
most reliable remedy is simple excision. For this purpose an instrument 
having a circular blade can be used with entire ease in taking off the 
gland to a level with the surrounding parts, which is all that is necessary. 
What is left of the gland after the most prominent part has been thus 
excised, shrinks after cicatrization of the surface and causes no further 
inconvenience. Patients from whom the tonsils have been thus excised 
very rarely remain susceptible to fresh attacks of inflammation in these 
parts. If there be objection from any cause to excision of the tonsils 
when permanently enlarged, they may be reduced to such a degree as to 
render them comparatively harmless by persevering applications, either 
of nitrate of silver, sulphate of copper, or iodide of zinc. These applica- 
tions to be effectual should be made at least once every day, and of suf- 
ficient strength either to deaden or decidedly cauterize the surface to 
which they are applied. They are most easily applied in the form of 
strong solutions, with a camel's hair pencil, the application being restricted 
of course to the surface of the enlarged tonsil. Their effects, generally, 
are slow, and consequently require to be continued with much patience 
in order to obtain success. This fact of itself, constitutes an additional 
reason for resorting to excision, whenever the patient will consent to it 
and is free from complications of a scrofulous tendency or coincident 
scrofulous enlargement of the lymphatic glands. In the last named 
cases excision had best be omitted ; first, because the portion of the 
tonsil remaining will often slowly increase until the tumor is reproduced 
in the fauces, and as troublesome as before ; secondly, for the reason that 
all such patients require careful and persistent treatment, medicinal and 
hygienic, for the removal of the constitutional scrofulous affection, and 
the same treatment which is most efficient for this purpose will itself 
generally remove the hypertrophy of the tonsils. 

Inflammation of the Oesophagus. — Simple idiopathic inflammation in 
any part of the oesophagus is of more rare occurrence than in any of the 
structures to which I have alluded. Nearly all the cases that come 
under the care of the practitioner arise from the action of direct irritants ; 
such as food and drink taken too hot, or acrid substances swallowed 
without proper dilution, or the accidental swallowing of corrosive and 
irritant poisons. From any of these causes inflammation may take place 
in the oesophagus, varying in intensity from the slightest blush of rednes?, 



SYMPTOMS. 511 

boat and smarting produced by a slight scald or burn, to that of the most 
intense inflammatory action and even corrosion. The slighter grades of 
inflammation arising from swallowing too hot or slightly irritant substances 
usually disappear spontaneously in from three to four days, by having the 
patients simply abstain from the use of coarse food and live during that 
time upon some bland, unirritating substances, and perhaps swallow once 
in three or four hours a spoonful of simple mucilaginous drink, rendered 
cold by ice. 

In the more severe inflammations produced by corrosive and irritant poi- 
sons usually no other means than those just named, keeping the patient at 
rest, keeping up nutrition with as little use of the oesophagus as possible, and 
having what does pass through it, of the most bland, unirritating character, 
will constitute the best mode of treatment that can be devised. Inflamma- 
tions excited by these substances are very liable to be followed, especial- 
ly when erosion and destruction of more or less of the lining membrane 
has taken place, by contraction after cicatrization, sufficient to leave more 
or less stricture of the oesophagus, permanently interfering with the process 
of deglutition, sometimes rendering it almost impracticable lor the patient 
to take sufficient nourishment through the constricted tube to prevent 
starvation. Such cases, if remedied at all, must be remedied by surgical 
interference, chiefly through well directed efforts toward dilating the 
constricted portion of the tube. There is a form of stricture of the oesoph- 
igus occasionally met with dependent upon morbid sensitiveness of the 
nerves supplying the muscular coat of some portion of this organ. It is 
seldom idiopathic in its nature, but is a reflex form of disease located 
in some other part of the nervous system. The symptoms in such cases 
are not such as to suggest the idea of inflammation, there being no fever, 
seldom pain in the part, and at times the patient performs the act of deg- 
lutition without difficulty. But when he attempts to take food, the con- 
tact of the latter with the sensitive nerves of the fauces, or com- 
mencement of the oesophagus, causes an immediate spasmodic contrac- 
tion of its circular fibres, thus making a temporary stricture sufficient to 
irrest the progress of the food downward, and hold it for a few seconds, 
when not infrequently it regurgitates backward into the mouth and is re- 
jected, or the stricture yields and allows it to pass into the stomach. 

These cases are distinguished from inflammation of the oesophagus by the 
absence of heat, pain and sense of soreness in the part, and by the absence 
Df any general febrile disturbance. They are distinguished from per- 
manent contraction of the oesophagus from causes that I have already 
mentioned, or from development of malignant growths upon the 
oesophagus, by the fact that often after the food and drink has 
been arrested for a few seconds it is allowed to pass, and in the 
intervals between taking it no sense of obstruction exists, and still 
more by the fact that upon exploration of the oesophagus with a probang, 
the instrument will often pass unobstructed through the whole length of 
the tube to the stomach, or if its presence induces, like the presence of 
food, a spasmodic contraction and arrest of its progress, simply allowing it 
to remain, with slight steady pressure the stricture will usually yield 
and allow free passage of the instrument into the stomach. One of the 
most singular spasmodic strictures of the oesophagus, coming under my 
own observation, was that of a tailor who in a quarrel with a fellow tailor 
received a blow upon the occipital region of his head with a press-board. 
The blow merely stunned him for a moment, from which he recovered 
sufficiently to return to his home without difficulty. It was followed by 
no symptoms of cerebral disturbance or febrile reaction, but, immediate- 



512 GASTRITIS. 

Iy there was total inability of the patienttopass anything into his stomach. 
Everything given h im would pass a little way down the oesophagus, be 
held for a few seconds, and regurgitated. The patient remained in this 
condition from seven to nine days without swallowing the smallest quan- 
tity of either food or drink. Being called to the case and learning its 
history, I caused the patient to make an effort to swallow, but without 
success. Considering the length of time he had been without nourish- 
ment, I immediately attempted to pass the stomach- tube of an ordinary 
stomach pump through the oesophagus, for the purpose of introducing 
nourishment through it into the stomach. When the end of the stom- 
ach-tube had reached about one third of the length of the oesophagus 
downward, its progress was arrested. But on making steady, moderate 
pressure, for perhaps ten seconds, the obstruction seemed to give way 
rather suddenly, and the tube passed on to the stomach without further 
difficulty. Through it, was passed a little more than a pint of fresh 
milk, and the tube withdrawn. In a few hours the patient found that he 
could swallow liquids without difficulty, and from that time he took food 
and drink freely. 

Acute and Chronic Gastritis. — The word gastritis is usually applied to 
inflammation of the mucous membrane of the stomach. The inflamma- 
tion of this membrane in some of its forms or degrees of activity is met 
with frequently, in the ordinary duties of the practitioner. The particular 
grades or varieties of the inflammation met with, are, first, diffuse general 
inflammation of the mucous membrane, which may be either acute or chron- 
ic; second, follicular inflammation which is generally of very limited ex- 
tent and chronic in its grade; and, third, ulcerative inflammation or more 
properly chronic gastric ulcer. The first variety or diffuse inflammation 
of the mucous m mbrane is rarely met with in the acute form, except as 
the result of the direct application of irritating substances, as in swallow- 
ing acrid poisons, substances of too high a temperature, or from mechan 
ical injuries. But occasionally, cases of genuine acute gastritis occur 
from such ordinary causes as produce other acute inflammations. 

Symptoms. — Acute gastritie, when it does occur, either as an idiopathic 
affection, or as the result of irritating ingesta, commences with a burning 
pain in the epigastrium usually becoming early very intense, like burn- 
ing coals of fire in the stomach, dryness of the mouth, intense craving 
for cold drinks, a decided sense of oppression in the epigastrium, 
pain, not infrequently extending through to the central part of the 
spine, constant feeling of nausea, with frequent efforts at vomiting, and 
the pi ompt rejection of food and almost everything that is taken, even of 
the blandest character. Each act of vomiting is accompanied by increased 
epigastric distress and tenderness. The matters ejected, aside from what 
has been swallowed, consist of a thin mucous or serous fluid, usually 
tinged with the coloring matter of bile, sufficient to give it a green or 
yellow hue. The pulse in the first stage is usually quick and small, 
corded and tense, sometimes called wiry; the skin over the trunk of the 
body is hotter than natural, and dry, and the extremities often cold. The 
bowels usually are inactive, not obstinately constipated but simply in- 
disposed to move at the ordinary intervals of time, and the quantity of 
urine is usually very scanty and high colored. In the most acute form 
of the disease the patient becomes rapidly prostrated, the pulse after the 
first twelve hours becoming thready, small, weak, the extremities more 
cold, often purplish or bluish, face pinched, eyes sunken, lips thin, mouth 
very dry, parched, edges and tip of the tongue redder than natural, the 
mind frequently wandering or incoherent, the abdomen bloated and 



SYMPTOMS. 513 

tympanitic, epigastric region exceedingly tender to the touch, so much so 
that the patient shrinks at the approach of the hand, and in most instances 
will not bear even the weight of a sheet upon the body. 

From this time the matters vomited become larger in quantity; instead 
of a greenish fluid as at first, the color becomes dark brown, mixed with 
flakes; and the efforts at vomiting are still frequent, exceedingly distress- 
ing, and are promptly induced by anything that is taken into the stomach. 
If relief is not afforded, in some instances the failure of strength and 
vitality in the patient is so rapid, that after from twenty-four to thirty-six 
hours from the commencement of the attack, the urine is entirely sup- 
pressed, involuntary discharges take place from the bowels, the vomiting 
becomes more of a regurgitation, throwing out large quantities of dark 
grumous fluid, almost as black as the matter of black vomit in yellow 
fever. In a little time the pulse can no longer be felt at the wrist, the 
heart beats rapidly, with paroxysms of tumultuous palpitation, the mind 
becomes dull and drowsy, the abdomen extremely tympanitic and dis- 
tended, and before the end of another day, entire collapse and death 
ensues. Cases of acute gastritis have been known to terminate fatally 
within twenty-four hours; but more generally the disease, even in the 
more acute form, continues from three to five days. And in a less acute 
form the symptoms that I have described may be protracted over a period 
of from one to two weeks, and yet terminate fatally. In some instances 
the commencement of an attack of gastritis is marked by chilliness of 
brief duration; but in nearly all the cases that have come ui. Jer my own 
observation, no period of chill has been noticed. The symptoms super- 
vene, as I have already described, from the beginning as the result of 
extreme gastric sensitiveness, the chief complaint at the first being a 
burning, broiling pain, and a most incessant disposition to vomit. Cases 
are met with that merit more the name of subacute than acute gastritis. 
These cases commence with the same symptoms, in a less degree of inten- 
sity, accompanied by less rapid pulse, less activity in all the morbid 
phenomena, and are protracted usually five or six days until the patient 
becomes much exhausted, and the pulse feeble, when the paroxysms of vomit- 
ing begin to be farther apart, the burning sensation in the stomach less 
intense, and small portions of cold, mucilaginous, bland liquids will be re- 
tained at least for a little time. The urinary secretion, diminished in the ear- 
lier stages, increases again as the disease passes its climax, the thirst becomes 
less urgent, but at the end of the second week, or from nine to fourteen 
days, the inflammatory action will have so far subsided, that the patient 
begins to show indications of convalescence. The stomach is still irri- 
table, whenever the patient ventures to take more than very small quan- 
tities of bland material at a time; but small quantities are retained with- 
out much distress, and from day to day more is tolerated until the symp- 
toms of undue excitability disappear. 

The most acute form of gastritis is always a dangerous disease, and 
terminates fatally in the large proportion of cases. The milder attacks, 
properly denominated subacute, under any reasonably judicious manage- 
ment, will generally terminate in recovery. Two forms of chronic inflam- 
mation of a diffuse character are met with in practice. The first is 
generally the sequel of a previous acute or subacute attack. The 
primary subacute disease continuing its course for two or three weeks, 
only partially subsides, leaving the patient with a feeling of tenderness on 
pressure in the epigastrium, a sense of heat and dryness in the mouth 
and in the stomach, a desire for cold drinks, usually an aversion to taking 
food, or loss of appetite, an inactive condition of the bowels, slightly dimin- 
33 



514 CHROMIC GASTRITIS. 

ished secretion of urine, with skin dry, lips unnaturally dry and parched, 
edges and tip of the tongue redder than natural, pulse usually moderately 
accelerated, varying from ninety to one hundred, especially in the after- 
noon and evening. The mind is usually depressed, gloomy and despondent. 
The feeling of distress and burning in the epigastrium is greatly increased 
whenever food of any kind is taken into the stomach ; and unless it is 
taken in small quantities and of a very easily digestible character, it is 
usually followed by the generation of acids, and often in from half an hour 
to an hour or more the food is rejected by vomiting in a sour and only 
partially digested state. In this condition the patient usually retains 
enough of nourishment to prevent rapid emaciation and loss of strength, 
and m9.y consequently continue to suffer fnm the disease an indefinite 
period of time. In a few instances that have come under my care, the 
patients have been afflicted with a chronic form of inflammation of the 
mucous membrane through periods varying from one to three years. In 
these old cases, the patients have uniformly been much emaciated, skin 
exceedingly dry and husky, lips thin, pale and more or less retracted, 
the countenance anxious and depressed in its expression, the pu:se small 
but firm under the finger, respirations about normal, the urinary secretion 
pretty uniformly scanty and high colored, the tongue in these cases has 
presented a glossy reddened appearance over nearly its whole surface, 
with frequent, small, apthous, irritable ulcers along its margin, 
and sometimes in other portions of the mouth. The abdomen has 
usually presented a concave or empty condition, the bowels seldom 
moving oftener than once in three or four days, unless disturbed by 
artificial means, while everything in the form of ingesta taken into the 
stomach is followed either by prompt rejection by vomiting, or being 
retained it soon creates that distress and feeling of heat and burning 
that lasts usually from two to three hours, sometimes ending in vomiting 
of a sour acrid liquid, the food itself having disappeared; and when no 
vomiting occurs it gradually subsides by the apparent discharge of what 
had been taken through the pyloric orifice into the parts below, leav- 
ing the stomach empty. The other form of chronic gastritis to which 
I alluded is perhaps more properly designated as a hyperesthesia 
-or morbid sensitiveness of the mucous membrane than a true chronic 
inflammation. Its symptoms are undue sense of heat and tender- 
ness in the epigastric region, increased by taking any kind of 
nourishment, a tendency either frequently, in a few minutes, to reject what 
has been taken, or when retained a gradual increase of the burning, 
and sense of distension, more or less nausea, and generally the 
generation of sufficient acid material to cause either the whole to be 
rejected in from half an hour to an hour, or eructations of acid to come up 
the oesophagus to the pharynx, causing an acrid sour taste in the mouth 
until the contents of the stomach pass through the pyloric orifice, 
when the active symptoms gradually subside, till further ingesta are 
taken. In most of these cases, however, the patients reject the larger 
part of what they eat within a few minutes after it is taken, and before it 
has had time to undergo any appreciable change. In these cases when 
the stomach is allowed to be entirely empty there is a vague sense of un- 
easiness accompanied by a gnawing or desire for food, but no sooner is 
the food taken than, as I have already remarked ; it is either promptly 
rejected, or it aggravates the suffering of the patient until it pass s through 
the pylorus. 

Follicular Inflammation. — The prominent symptoms occasioned by 
inflammation of a chronic character, limited to the follicles of the mucous 



SYMPTOMS. 515 

membrane, are usually of a milder character than those I have described for 
the preceding forms of disease. In most of the cases of this class, the pa- 
tients exhibit no marked febrile symptoms, neither the pulse, respiration 
nor temperature varying much from the natural standard. The secretions 
generally are but little interfered with, although the bowels are usually 
constipated or decline to move without prompting. The patients do not, 
usually, complain of epigastric tenderness, or if so it is slight. In most 
instances they take food with comparative relish, and for one or two hours 
after eating, they experience no other inconvenience than a slight feeling 
of heaviness. Indeed, most of this class of patients say promptly, that 
they feel better for the next hour or two after they take food, than they 
do at any other time. But, in from an hour and a half to two hours after 
they eat, they begin to experience a feeling of moderate heat, undue full- 
ness, and oppression in the epigastrium, which increases steadily until 
the next meal. Others have a turn of vomiting by which they will reject 
from one to five ounces of a thin serous fluid, sometimes a little sour or 
acrid, but more generally tasteless ; after which they are relieved. In 
other instances they do not vomit, but continue to feel more and more 
uneasy in the epigastric region until the next meal, when on taking food 
all uneasiness quickly vanishes, and as before, from one to two hours of 
comparative comfort ensues, when the same tendency to distress, heavi- 
ness, burning and gnawing sensations return and increase steadily until 
either vomiting, or the time for the next supply of food occurs. 

In the milder cases of this class, the patient on rising from bed in the 
morning, and sometimes even before they get out of bed on first awaking, 
will feel a very decided sense of oppression and fullness in the epigastrium, 
with a constant nausea and disposition to vomit, which ends in the ejection 
by vomiting of a few ounces of the same thin serous fluid, to which I have 
before alluded; most generally tasteless and odorless, but in some instances 
slightly acrid, and in others a little acid. After rejecting this, they take 
their breakfast with comparative relish, experience no inconvenience 
until near the time of the next meal, when they feel oppressed, the 
stomach has a disagreeable sensation that they call gnawing or hunger, 
which ends only with their taking food. In some instances the feeling 
of distress and hunger will return in the middle of the night to such an 
extent, that the patient can appease it in no other way than by taking a 
small quantity of food, and then it quickly disappears. When the disease 
is more active, and a larger proportion of the follicles or gastric tubules 
are involved in the inflammatory action, the food is usually dissolved and 
passed out of the stomach by absorption, or into the duodenum in a 
remarkably short time. The secretion and accumulation of fluid after 
the food is digested and has passed out of the stomach, is so rapid that 
vomiting of a watery substance occurs pretty regularly, an hour or 
two before the time for the next meal; but it is never mixed with any of 
the food that has been taken. This has been previously dissolved, and 
rapidly passed out of the stomach, and what is vomited is only the 
secretion from the follicles or gastric tubules of the mucous membrane 
itself. A large proportion of these cases are of the milder class ; and the 
vomiting only occurs in the morning. They are popularly styled cases of 
pyrosis or water-brash. They are far more frequently met with in persons 
addicted to the use of alcoholic drinks than in any other class, although 
not restricted exclusively to them. Occasionally the phenomena I have 
described occur during pregnancv, but not often. 

If you study the phenomena of this form of gastric disease carefully, you 
will readily perceive that they indicate just that grade of irritation or in- 



516 GASTRITIS. 

flammator}' action, which causes an increased secretion of serous fluid, 
composed usually of a mixture of the serous exudation from the irritated 
follicles, and of the true gastric juice, showing that the irritation involves 
both the follicular structures and the gastric tubules. In the natural or 
healthy condition of these structures, especially of the gastric tubules, the 
secretion of gastric juice only takes place, actively, during the reception 
and the presence of food in the stomach, and ceases as soon as the stomach 
becomes empty. But in these cases the morbid condition of the structures 
causes the secretion to be continuous, and consequently it tends rapidly 
to accumulate in the stomach, when there is no food present with 
which it can be mixed and united as in the process of digestion. The 
patient takes food, and while the food is in the stomach, it mixes and 
more or less chemically unites with the ingredients of the secretion, and 
consequently relieves the patients from his morbid sensations. The food 
is thus rapidly converted into chyme, and passed out of the stomach. But 
the secretion goes on the same, and hence very soon begins to be a 
cause of increased irritation and distress, and sometimes vomiting. 



LECTURE LII. 



Gastritis, Acute and Chronic. Continued— Gastric Ulcer— Anatomical Change? In all Grades of 
Gastritis— Diagn.j^is, Prognosis and Treatment— Duodenitis, etc. 

GENTLEMEN: The only remaining form of inflammatory disease in 
the stomach requiring notice is called the gastric ulcer. The symp- 
toms in the early stage can hardly be distinguished reliably from those 
belonging to cases of ordinary indigestion or slight irritation of the 
mucous membrane. There is no continuous pain, tenderness in the epi- 
gastrium or febrile phenomena; but for several months after the com- 
mencement of the disease, the patient will occasionally, after taking more 
food than usual, be troubled with some feeling of soreness, acid eructa- 
tions, some burning in the stomach for an hour or two, but by being 
more cautious in taking food he experiences so little inconvenience 
that no importance is attached to the case. After the continuance of these 
vague symptoms an indefinite period of time, perhaps suddenly, without 
any previous warning, the patient feels a sense of distension and warmth 
in the stomach, soon developing into nausea, and then copious vomiting, 
by which he ejects a large quantity of dark and partially coagulated 
blood. The quantity of blood varies much in different cases. In some it 
will be small, not more than an ounce or two, but in the majority of cases 
the quantity will amount to from eight to thirty ounces, filling an ordinary 
wash-bowl half full. It is always dark-colored, free from any intermix- 
ture of air bubbles, and very generally partially coagulated. These 
features distinguish it, at once, from blood coming from the lungs, which 
is always brighter colored and more or less mixed with air. The first 
attack of hsematemesisor vomiting of blood will generally be of very short 
duration, but it leaves the patient paler, the pulse slightly quickened, the 
stomach more sensitive to the contact of food or drink, and with some slight 
epigastric tenderness. 



SYMPTOMS. 517 

By rest and abstinence from all but bland, simple nourishment, these 
symptoms subside in a few days, and the patient appears the same 
as before the haemorrhage, except that his color usually remains of a more 
anaemic hue. The patient seldom recovers the fresh natural color of the 
lip, that he had before. Most generally, after the first turn of vomiting 
blood, during the two or three hours following each meal the 
patient continues to experience a little more distinct feeling of 
heaviness, or discomfort. Many days this will only be slight, at other 
times it will be more marked, and usually, after a few months, the symptoms 
of indigestion become more constant, accompanied by eructations 
of gas, and sometimes acrid or sour liquids. There will remain also 
a vague sense of tenderness in the epigastrium, more readily increased 
by pressure than in the earlier stage. These symptoms, however, are only 
those that often characterize common cases of functional disturbance of 
the stomach; but, usually in a period varying from one to six months 
another hemorrhage will occur of the same character as the first. The 
patient spontaneously vomiting pretty copious quantities of dark, par- 
tially coagulated blood, the first ejected being mixed in most cases with 
the contents of the stomach. This leaves the patient still more anaemic 
than after the first, but usually does not prevent him from again recover- 
ing so far as to resume more or less his ordinary duties of life, and to 
retain most of his food and drink. Thus he may pass one, two 
or three years, the hemorrhages occurring at long intervals at first, but in- 
creasing in frequency with each return, until the red corpuscles of the 
blood become very deficient, and the strength much impaired, when with- 
out loss of flesh or weight, he is seized with an acute or intensely sharp 
pain, in the region of the stomach. More frequently, the pain is felt in 
the left hypochondrium as if proceeding from the larger curvature of the 
stomach; but the location may vary in different cases, from near the epi- 
gastrium, to the extreme left curve of the stomach. This acute sudden 
pain is followed immediately by a sense of weakness, exhaustion, pallor 
of the countenance, small, thready pulse, cold extremities, and in a little 
while by vomiting. He throws off whatever is on the stomach at the time, 
and promptly rejects whatever drinks are taken, the abdomen becomes 
rapidly tumefied, tympanitic, the urinary secretion lessened or suppressed, 
the matter rejected by vomiting more copious, watery, first tinged with 
green from the coloring matter of the bile, subsequently by the action of 
the acids in the stomach, changed to a dark brown, or black, and gulped 
up more by regurgitation than by acts of vomiting. There is extreme 
distension of the abdomen, a purplish or leaden hue of the extremities, 
entire collapse and death. The latter takes place in from twelve to twenty- 
four hours from the time of the attack of acute severe pain. Such is the 
general history and termination of what is denominated chronic gastric 
ulcer. 

The explanation of these phenomena consists in the fact, that, from 
the beginning the ulcer had been established in some portion of the mu- 
cous membrane of the larger curvature of the stomach, which gradually 
increased in size with thickened elevated edges, at the same time progress- 
ing deeper into the structure of the stomach and at various times during 
its progress eroding some blood vessels of sufficient size to occasion the 
hemorrhages that I have described. Ultimatelv it perforates all the coats 
of the stomach, opening into the peritoneum, giving rise to the last sudden 
severe pain, and allowing some of the contents of the stomach to es- 
cnpe into the peritoneal cavity, inducing rapid general peritonitis, col- 
lapse and death. In some of these cases the amount of blood vomited is 



518 GASTRITIS. 

very large. In one case, coming under my own observation, I think 
without exaggeration of statement, the patient vomited in the course of 
cwenty-four hours between one and two litres (three and four pints) of 
blood. And, yet, these hemorrhages very seldom prove fatal by direct 
exhaustion of the patient. Far the larger proportion of cases end in per- 
foration and peritonitis, instead of dying from the quantity of blood lost. 

Anatomical Changes and Post-mortem Appearances. — The anatomical 
changes produced by the different varieties of inflammation I have 
described, vary with the intensity, extent, and duration of the 
inflammatory process. In fatal cases of acute gastritis the mucous 
membrane appears intensely injected, somewhat tumefied, and vary- 
ing in color from an intense bright red to a dark brown; the 
latter giving rise to the idea sometimes, of a gangrenous condition. 
There is almost always more or less softening of the membrane, and fre- 
quently the redness and increased vascularity presents a stellated appear- 
ance, as though radiating in lines from a common center. Examined 
more closely with the microscope the same changes are found here as in 
almost all other acutely inflamed structures, namely, exudation of the liquor 
sanguinis and white corpuscles into the texture of the membrane, prolif- 
eration or increase of the epithelial cells belonging to the surface, and some 
hypertrophy of the connective tissue — all of which tend to make the mem- 
brane appear thicker and more tumefied than natural, and of various 
shades of increased redness. In places there is detachment of much of 
the epithelial la- er, and a loosening or softening of the texture. In 
some instances this softening amounts almost to actual disorganization of 
the texture. It is this loss of tone, or partial disorganization of the mem- 
brane in the last stages of the acute form of the disease that allows co- 
pious exudation, carrying with it more or less of the red corpuscles of the 
blood, changed to a blackish hue by the acids of the stomach, which con- 
stitutes the dark grumous material that is thrown up in such quantities 
about the time the patient is passing into final collapse. The same fluid is 
not infrequently found in considerable quantity in the stomach after death. 

In many of the subacute cases of the disease, especially those which run 
a more protracted course, and finally terminate fatally, some portions of the 
mucous membrane will be found intensely red and tumefied, with all the 
changes that I have previously mentioned, except, that instead of softening, 
the exudative material will have sufficient plastic' ty to give it increased 
hardness or densitv; while other portions being less involved in the inflam- 
mation, are simply reddened or more vascular, with but little change either 
in the direction of induration or softening. In the purely chronic grade of 
inflammation, there is generally a very unequal degree of change in 
different parts of the membrane. Some portions will be thickened, 
hardened, more red and vascular than natural, and the surfaces will 
be studded with abrasions or superficial ulcerations, caused by the 
d : sappearance, in patches, of the epithelial layer of the membrane. Other 
portions will be simply increased in vascularity, slightly thickened, 
tumefi ^d and indurated, without anv appearance of the abrasions upon 
the surface, and the redness will be of a brighter hue. The cases which I 
have described as follicular, will present, usually, patches here and there, 
unequally distributed over the surface of the mucous membrane, of 
simply hypertrophied or enlarged follicles and tubules, giving to such 
places a slightly reddened and elevated appearance, sometimes granular 
or mammillated, and when they are examined more closely, especially 
under the microscope, they will be found to consist of hypertrophied 



DIAGNOSIS. 519 

tubules and follicles, possessing all the characteristic changes of a low 
grade of inflammatory action. After death from chronic gastric ulcer, 
examination of the stomach usually discloses one, and occasionally two or 
three distinct isolated ulcers ; more generally but one, and this may vary 
in size from five to twenty- five lines in diameter. The edges are very 
generally elevated and a little rounded, though sometimes excavated and 
irregular. The greater part of the base of the ulcer is usually the naked 
fibers of the muscular coat of the stomach. In places these fibers may 
have disappeared, causing the base of the ulcer to rest upon the con- 
nective tissue between the muscular fibers and peritoneal covering 
externally. If the patient has died from perforation, in one of these 
deeper indentations will be found a small opening directly through 
into the peritoneal cavity, through which matters have escaped, 
inducing the final rapid and fatal peritonitis. Usually both the 
edges and base of the ulcer are harder or more dense than the 
natural texture, with a moderate degree of redness and increased 
vascularity surrounding them. But in many instances the remainder of 
the mucous membrane will vary but little from its normal, healthy 
appearance. Such are the changes of structure and the appearances, that 
are usually presented on post-mortem examination, from the various degrees 
and stages of inflammation in the mucous membrane of the stomach. 

Diacpwsis. — In the great majority of instances there is little difficulty 
in making a correct diagnosis of these different grades of gastritis. In the 
acute and subacute forms of the inflammation, the intensity of the 
burning or sense of haat in the stomach, the acute tenderness on pressure, 
the prompt and persistent vomiting, aggravated by every attempt to take 
nourishment, accompanied by a distinct general febrile condition, suf- 
ficiently distinguish these cases from any form of functional disease. 
There is more difficulty in keeping the line of diagnosis clear between 
the lower grades of chronic gastritis and some of the more active 
functional disturbances of the stomach. If you remember, however, that 
true chronic gastritis, is uniformly aggravated by taking food, and that 
the chief symptoms of which the patient will complain in the exacerbations, 
are burning, broiling in the epigastrium, dryness in the mouth, a pretty 
uniform reddening of the edges and tip of the tongue, and disposition 
sooner or later to eject whatever is taken, by vomiting, with more or less 
sourness, the almost invariable absence of gaseous eructatioi.s, with loss 
of flesh, slight quickening of the pulse, an increase of one or two degrees 
of temperature, you will have but little difficulty in making an accurate 
diagnosis. It is the association of burning and tenderness, persistent 
from week to week, with actual dryness of skin, slight acceleration of 
pulse, and elevation of temperature, that especially distinguish the chronic 
form of gastritis from any of the forms of functional disease. The 
follicular form of the disease has these special diagnostic features: that the 
morbid sensations are relieved for a time by taking food, aggravated as 
soon as food disappears, and there is a characteristic vomit that is called 
" water- brash" or pyrosis, as I have already stated, when speaking of the 
symptoms. 

Gastric ulcer can seldom be distinguished from functional disturbance 
with certainty, in the early stage of its progress. But the first hemorrhage 
that occurs, if it be properly interpreted, will at once satisfy the practitioner 
that he has a positive lesion in the coats of the stomach to contend with, 
and thus the preceding obscure history becomes an element to add to the 
certainty of the diagnosis, and to fix it as a true chronic form of ulcer- 
ation. 



520 GASTRIC ULCER. 

Prognosis. — The more severe attacks of acute gastritis al\va}'S involve 
some danger to the life of a patient. Experience has shown that the 
larger proportion of them terminate fatally. The milder cases of the 
acute and most of the subacute attacks, under judicious management, 
tend to recovery. In the earlier stage of chronic gastritis the chances 
of recovery are usually good. But when the disease has been of long 
standing, causing much thickening and induration of portions of the 
mucous membrane and subjacent connective tissue, with permanent con- 
traction of the muscular coat, in such a way as to lessen the capacity of 
the stomach, it is rare that recovery takes place; although the symptoms 
of the patient may be much mitigated by judicious treatment, and life 
may be prolonged through a considerable period of time. Most of the 
cases of recent follicular inflammation of the mucous membrane of the 
stomach tend to recovery under judicious management; but some are 
very persistent, and occasionally end, either in such changes in the 
follicles, or atrophy of the gastric tubules, as to present an incurable con- 
dition. Such cases interfere with the proper assimilation of food, and 
lead to a slow, but persistent loss of flesh and strength, and usually 
require several years to reach a fatal result. The chronic gastric ulcer, 
if diagnosticated early, and if the patient is placed under the most favorable 
circumstances in regard to diet and remedial agents, is susceptible of 
recovery; but when it has been of considerable duration, has attained 
considerable size, with elevated and somewhat hardened edges, it is most 
liable to resist all efforts to induce reparation, and to lead ultimately to a 
fatal termination. 

Treatment. — The special objects to be accomplished in the treatment 
of acute and subacute cases of inflammation of the mucous membrane of 
the stomach, are the same as are presented to us in the management of 
all acute inflammations, But we are here met with a peculiar difficulty, 
from the fact that the very structure on which we ordinarily rely for intro- 
ducing remedies into the system, is now the seat of the inflammation, 
causing a disposition to reject all remedies almost as soon as they are per- 
mitted to touch the membrane. When called to a case of acute gastritis 
within a few hours after its commencement, the patient not having been 
previously debilitated by any special disease or constitutional impairment, 
I have usually directed the application of from eight to twelve leeches to 
the epigastrium, in adults, promoting the bleeding from the bites by w T arm 
wet cloths, after the leeches have fallen off, and subsequently allowing 
the part to be covered with warm narcotic fomentations. Free local 
bleeding by leeches in the very early stage of the disease, has seemed to 
me to exert a very beneficial influence in checking its progress, and 
making the action of other agents more certain. 

At the same time of ordering the leeches, I direct, if possible, the pro- 
curement of ice, to be cut in suitable pieces, and the patient allowed to 
take a small piece, holding it in the mouth until the angles are a little 
rounded and swallowing it at frequent intervals, in place of taking any 
other drink. As there is intense burning heat in the stomach, and craving 
for cold drinks, the use of the ice is very grateful to the patient, and 
serves the purpose both of acting as a sedative in diminishing the vascu- 
larity of the mucous membrane, with which it comes in contact when 
swallowed, and of satisfying the patient without the use of drinks, which 
would only increase the distress and efforts to vomit. To help allay the 
extreme morbid sensitiveness of the mucous membrane, and lessen the 
accumulation of blood in the vessels, I also direct at the beginning, a 
powder composed of the mild chloride of mercury, six centigrams (qr. i) 



TREATMENT. 521 

the sulphate of morphia one centigram (gr. 1-6), with three decigrams 
(gr. v) of saocharum alba, to be given mixed with just enough syrup, or a 
lew drops of water, to moisten it, every one or two hours, allowing a bit 
of ice to be taken immediately after, in place of any drink. Although 
the vomiting will cause the rejection of a portion of these small doses of 
calomel and morphine, still experience shows that some portion of 
each dose attaches itself to the coats of the stomach, and is retained. By 
their frequent repetition in from six to eight hours, the patient will usually 
begin to exhibit the anodyne effects of morphine, in getting more rest, 
longer intervals betweeu the paroxysms of vomiting, and at the end of 
twenty-four hours in many of the cases, the patient will be catching periods 
of from half an hour to an hour of sleep, and vomiting much less fre- 
quently. If during the first twenty-four hours of the treatment, there has 
been no evacuation of the bowels, I cause the administration of an ene- 
ma of warm water, containing a little common salt, or sulphate of mag- 
nesia, the quantity of water being sufficient to fill up the rectum, which 
will usually be followed by a moderately free movement of the bowels. 
Instead of continuing the powders of calomel and morphine I now give a 
solution of carbolic acid, tincture of gelseminum, and camphorated tincture 
of opium, in the proportions I have already stated in previous lectures. (See 
p. 138.) After the patient has had the alterant and anodyne powders, which 
1 have mentioned, for twenty-four hours, and the bowels have been moved 
by enemas, with a continuation of the fomentations of a narcotic character 
over the epigastrium and abdomen following the leeching, the powders 
should be discontinued and the carbolic acid solution given every two or 
three hours. This treatment has usually been followed by a pretty rapid 
subsidence of all the inflammatory symptoms, after which the intervals 
between the doses of the mixture should be lengthened to three or four 
hours, still being exceedingly cautious of the amount of fluid and nourish- 
ment that the patient takes. In nearly all the milder cases of acute gas- 
tritis and in all of those of a subacute character so often met with in chil- 
dren, this plan of treatment has been almost uniformly successful. 

The patients are kept entirely quiet in the recumbent position. No 
attempt at the administration of nourishment is usually made for the first 
thirty-six or forty-eight hours; but after that, simply one or two table- 
spoonfuls of lime-water and milk, one part of the first and two of the 
second are given at short intervals. Sometimes the animal broths, such 
as beef tea, chicken broth, and mutton broth, may be given in similar 
small doses, either alternately with the milk and lime-water, or as a sub- 
stitute for them. But the great leading object of the whole treatment 
should be to lessen the extreme excitability of the inflamed membrane by 
cooling, anodyne and slightly alterant influences, keeping all food from 
contact with it during the first one or two days, and allowing the use of 
only very small quantities of drink at any one time. In some instances, 
where the vomiting and epigastric distress are found to be extremely 
severe, and after one or two days it becomes evident that the little pow- 
ders of calomel and morphine are not retained in sufficient quantity to 
allay the morbid excitability, their effects may be aided by the use of a 
hypodermic injection of morphine. Better effects probably will be ob- 
tained, and at ieast less liability to have secondary nausea and depression 
follow the anodyne influence of morphine, if when used hypodermically, 
it is conjoined with a small quantity of atropia. In using hypodermic in- 
jections of morphine, I always prefer to use minimum doses at first, and 
incur the inconvenience of repeating it at proper intervals, rather than the 
r.sk of suddenly and too strongly narcotizing the patient by larger doses. 



522 GASTRITIS. 

In a few instances after the first twenty-four hours have passed, and the 
time come to procure a movement of the bowels, the use of enemas has 
failed to procure the necessary evacuations, and yet the abdomen has 
become largely distended with gases. Under such circumstances I have 
occasionally found the administration of a single powder, containing three 
decigrams each (gr. v) of calomel and bicarbonate of soda, followed in 
two hours by small but repeated doses of the liquid citrate of magnesia, 
to result in moving the bowels freely. My observations, however, have ied 
me to avoid the administration of cathartics by the mouth, while there is 
any considerable inflammation of the mucous membrane of the stomach 
still existing in the more acute attacks, unless it becomes absolutely 
necessiry from the failure of enemas, when they have been properly used. 
After the acute symptoms have passed by, the febrile action ceased and 
the patient is capable of taking and retaining small quantities of bland, 
simple nourishment, the greatest care is necessary to avoid all errors in 
diet, such as allowing the patient too early to return to the use of solid 
food, or to indulge with any degree of liberality in the use of drinks. 
It is also necessary to avoid too early a return to active exercise. Rest 
and extreme care in the regulation of the ingesta, will contribute very 
much to shorten the period of convalescence and render the patient's re- 
covery much more perfect than it would be were he indulged in an ear- 
lier return to more food, and more exercise. When the inflammation of 
the mucous membrane has assumed a chronic form, presenting the symp- 
toms I have described as characterizing that stage of the disease, it is sel- 
dom that much benefit can be obtained from local bleeding or from the 
use of what are called alterative medicines. In the great majority of cases 
of diffuse chronic inflammation of the mucous membrane, I have succeeded 
in affording much relief to the patient, by the use of nitrate of silver in the 
form of pills, usually in combination with the extract of hyoscyamus and 
opium. A pill composed of six centigrams (gr. i) of the extract of 
hyoscyamus, three centigrams (gr. £) of pulverized opium, and two 
centigrams (gr. -J) of nitrate of silver given each morning, noon, tea- 
time and bed-time, will usually produce a markedly beneficial effect. In 
some of these cases, I think the . carbolic acid solution to which I have 
already alluded given in doses of four cubic centimeters (fl. 3i) just before 
each meal time, and one of the pills of nitrate of silver, opium and hyos- 
cyamms given half an hour after breakfast, dinner and at bed-time, has 
produced better results than either of these combinations given alone. 
So far as practicable, during the treatment of chronic gastriti , the neces- 
sary intestinal evacuations should be procured by the use of enemas given 
at stated intervals, once a day, or once in two days, instead of laxatives 
administered by the mouth. In many cases of the milder grades of chronic 
gastritis of considerable duration and accompanied by habitual consti- 
pation of the bowels, I have used a pill composed of the sulphate of iron 
extract of hyoscyamus, and extract of Scutellaria, each six centigrams i 
(gr. i) with two centigrams (gr. -^) of gum aloes, and two of blue mass, 
given at each meal-time either before taking nourishment or within half 
an hour after, with a good effect upon the mucous membrane of 
the stomach, greatly lessening the distress after taking food, and in a 
few days establishing a regular and natural condition of the evacuations 
from the bowels. By taking from one to three of these pills daily, with 
careful regulation of he diet, drink, and exercise of the patient, they have 
been followed by recovery in many instances. Of course, I allude now, 
to those cases of a mild but persistently chronic character in which the in- 
flammatory action is barely sufficient to cause every meal, or supply of 



TREATMENT. 523 

food to be followed by a sense of heat, fullness, more or less nausea, and 
either eructations or occasional vomiting of the food in a sour condition. 
These symptoms with some degree of tenderness on pressure, I regard as 
indicating a low grade of inflammatory action in the mucous membrane. 

In many of this same class of cases I have succeeded well by giving the 
carbolic acid solution immediately before each meal and one of the same pills 
that I have just alluded to, only with the aloes increased to six centigrams 
(gr. i) instead of two (gr. ^) in each pill, at bed-time. In such cases the 
carbolic acid mixture (see formula on p. 138) exerts a beneficial influence 
in directly allaying the morbid excitability of the membrane and by 
its antiseptic properties lessening the tendency to sourness and acidity, 
while the pill with the increased amount of aloes taken at night serves to 
regulate the evacuations from the bowels. In many cases of chronic gas- 
tritis, persistent in their tendency, and accompanied by considerable epi- 
gastric tenderness to pressure, some advantage may be gained by mild 
but protracted counter-irritation. This may be accomplished, either by 
a succession of small blisters over the epigastrium, or perhaps better and 
with less annoyance to the patient by the application of a mixture of cro- 
ton oil one part, tincture of iodine two parts, sulphuric ether two parts. 
This painted ov,t so much of the surface, as you wish to make sore, at 
first twice in twenty-four hours, will usually in two or three days produce 
an eruption of vesicles sufficient to constitute a mild form of counter-irri- 
tation. After the eruption has taken place, it may be kept up by repeat- 
ing the application once a day, or once in two days, for such length of time 
as may be desirable. The treatment which I have usually found most 
efficient in relieving those cases which I have described as follicular in- 
flammation of the stomach has consisted in the use of sub-nitrate of bis- 
muth in doses of from three to five decigrams (gr. v to viii ) either 
alone, or combined at first with some anodyne, of which lupulin and hyos- 
cyamus are the best. Opiates in these cases, while they may temporarily 
help to allay irritation, seldom fail to induce within a few days, not only 
constipation, but a secondary nausea and depression that adds to the suf- 
fering of the patient, instead of affording any curative influence. The 
bismuth may be taken either immediately before the patient takes nour- 
ishment, or from fifteen to thirty minutes afterward. In cases in which 
there is a tendency to acid fermentation after taking food, I have thought 
it better to give bismuth in combination with an equal quantity of the 
bi-carbonate of soda, from fifteen to thirty-five minutes after taking food. 
In some of these cases, the oxalate of cerium, in doses of from two to' 
three decigrams (gr. iii to v) given before each meal- time, produces 
better effects than bismuth. There are still other cases, in which I have 
found bismuth, oxalate of cerium, and oxide of zinc, all to fail in produc- 
ing any permanent beneficial results; and yet the patients have been 
much relieved, and for a while entirely restored, by the use of pills com- 
posed of extract of hyoscvamus six centigrams (gr. i ) , and nitrate of 
silver two centigrams (gr. -§-) given just after each meal. In all these 
cases, whether using bismuth, oxalate of cerium, or nitrate of silver, due 
attention should be given to the procurement of regular evacuations from 
the bowels. In some instances the regular use of an enema, at a given 
time each day, will prove sufficient to obviate constipation, but in others 
it will be found ineffectual; and in such cases what I have called the tonic 
and laxative pill consisting of six centigrams (gr. i) each of extract of 
hyoscyamus, sulphate of iron, pulverized aloes, and blue mass, given at 
bed-time, each night, has seldom failed to establish in a few days a regular 
and natural evacuation once each day. The tonic properties of these 



524 CHRONIC GASTRITIS. 

pills may be increased by adding two centigrams (gr. -J) of the extract 
of nux vomica, or two milligrams (gr. 1-30) of strychnia to each 
pill. It is hardly necessary to add, that in all these cases of follicular 
inflammation, however chronic they may be, and whatever may be the im- 
pression of agents administered for their relief, it is necessary that the 
patient be cautious in the use of food and drinks; abstaining rigidly from 
all rich, highly seasoned dishes, coarse and indigestible vegetables or 
fruit, and taking only the plainer, simpler, and more easily digestible ar- 
ticles at regular intervals and in only moderate quantities. 

It is necessary, also, that strong tea and coffee be avoided. A cup of 
light, or weak tea or coffee taken at meals, in many cases produces no per- 
ceptible inconvenience. All alcoholic drinks or remedies should be care- 
fully excluded; especially is this important in those cases of follicular 
disease that have originated in individuals addicted to the habitual use 
of alcoholic drinks. My own observation does not enable me to agree 
with those writers, who in this particular class of cases especially, sanction 
a very moderate use of some of the lighter wines, under the impression 
that they enable the patient to retain nourishment better than they would 
without it. While this is apparently the case sometimes for a temporary 
period, I have never known it to be continued two weeks in succession 
without being followed by an aggravation of the symptoms; neither have 
I ever known a patient to continue the use of any variety of wine or beer, 
that obtained such kind of relief as enabled him to dispense with its use. 
In other words the apparent benefits derived from them have been either 
simply from the temporary anaesthetic effect of the small portion of alco- 
hol upon the morbidly sensitive condition of the gastric nerves, or they 
have produced no benefits, but a direct and positive injury: consequently 
I have long since insisted upon their entire discontinuance in all this 
class, of cases, and more particularly those which have originated prima- 
rily during their habitual use. In the treatment of the chronic gastric 
ulcer, the only other form of disease that I have included in the list of in- 
flammations of the gastric mucous membrane, I have more evidence of the 
curative effects of nitrate of silver given in combination, either with hy- 
oscyamus or small doses of opium, than of any other remedy. I have no 
doubt that when the disease is diagnosticated early, and the patient 
put upon a judiciously regulated diet, excluding all stimulating drinks, 
and irritants of every kind, and required to take nitrate of silver, com- 
mencing in doses of two centigrams (gr. -J) combined with six centi- 
grams (gr. i) of the extract of hyoscyamus, in the form of a pill, at 
each meal-time, and the doses of the silver gradually increased from time 
to time, until it reaches from three to five centigrams (gr. \ to f), the 
patient will usually find his obscure symptoms of indigestion, epigastric 
heaviness after taking food, gradually disappear, until there is no evidence 
of any derangement left. But in order to insure the entire success of 
remedies, the treatment must be continued a considerable length of time, 
usually not less than three or four months. Small doses of sulphate of 
copper, given in the same combination as I have mentioned for the nitrate 
of silver, have also sometimes proved equally beneficial, and in particular 
patients, more so than the nitrate of silver. 

At the time of hemorrhage from gastric ulcer, I have found no remedy so 
speedily successful in arresting the further oozing of blood, as suitable 
doses of persulphate of iron. I have usually given it in doses of from 
six to twelve centigrams (gr. i to ii) dissolved in eight cubic centimeters 
(fl. 3ii) of water, repeated at first every thirty minutes, till the flow of blood 
appears to be checked, then at intervals of one hour, gradually extending 



TEEATMENT. 525 

the time to two, three or four hours. If no return of the bleeding occurs for 
forty-eight hours, it may be discontinued. During the next week follow- 
ing those attacks of bleeding, I have used a pill, consisting of the sulphate of 
iron, six centigrams, (gr. i) with an equal quantity of the extract of 
hvoscvamus at each meal-time, and the same, to which was added one 
grain of aloes, at bed-time; the latter for the purpose of inducing a reg- 
ular condition of the intestinal evacuations. I have thought the use of 
the sulphate of iron for one or two weeks, following attacks of hemorrhage 
from gastric ulcer, rendered the patient more secure against the return of 
hemorrhage, and prepared the way for the subsequent use of the nitrate of 
silver, with much better results than when the nitrate of silver was re- 
sorted to immediately after the cessation of the hemorrhage. But the 
proper regulation of the patient's diet, in these cases of gastric ulcer is of 
quite as much, if not moro, importance than the medicines to be adminis- 
tered. All coarse and indigestible articles of food, and those of a heat- 
ing, stimulating nature, should be rigidly excluded. The best diet in 
most instances, is that composed principally of light-bread and milk, oat- 
meal and milk, rice and milk, or other farinaceous articles. For variety, 
meat broths may be allowed, but when used, they should always be sea- 
soned with salt to suit the taste of the patient, and not taken fresh or 
without salt. I have spoken of the administration of the persulphate of 
iron as the best remedy for the immediate arrest of hemorrhage from 
gastric ulcer; but there are many other remedies that may be used, and 
often with prompt relief to the patient. From six to twelve centigrams 
(gr. i to ii) of the acetate of lead may be given every twenty or thirty 
minutes, during the time of the flow of blood, and then continued at 
longer intervals for twenty-four or forty-eight hours, to prevent its recur- 
rence. Vegetable astringents, such as gallic acid, fluid extract of rhatany, 
or the geranium maculatum root, may be used ; but so far as my own ob- 
servations go, these vegetable astringents are much less reliable for the 
speedy arrest of this variety of hemorrhage, than either the acetate of 
lead, or the persulphate of iron. Ergotin is another remedy that, in re- 
cent times, has been used in this, as in many other varieties of hemorrhage, 
and sometimes with apparently prompt beneficial effects. It must not be 
forgotten, however, in estimating the effects of remedies, that in the large 
majority of these cases of gastric ulcer, the hemorrhage tends to cease 
spontaneously, within a brief period of time. Many patients, when at- 
tacked, living a few miles from their physician, have found the flow of 
blood to have ceased entirely before the physician has arrived, and with- 
out the agency of any remedies calculated to exert an influence over it. 
Simple rest in the recumbent position, avoiding all ingesta except the 
swallowing of pieces of ice or small doses of cold water now and then, has 
seemed to facilitate the arrest of the hemorrhage. 

Duodenitis. — The mucous membrane of the next section of the 
alimentary canal, called the duodenum, is much less liable to attacks of 
an inflammatory character, than that lining the stomach. Yet occasional 
instances of all the various grades of inflammation, to which I have called 
your attention, as occurring in the stomach, are met with in the duodenum, 
and the changes that are produced during their progress, anatomically 
and symptomaticaliy are identical with those which occur in the corre- 
sponding grades of inflammatory action in the membrane lining the 
stomach. The chief difference in the symptoms consists in the fact, that 
when the inflammation exists in the duodenum, the ingesta that the 
patient takes, whether food, drink, or medicine, does not produce its 
irritant effects so speedily. There is usually a brief period of time after 



526 DUODENITIS. 

it is swallowed, more generally extending to thirty minutes and sometimes 
longer, before the nausea, burning or distress of any kind, or the dis- 
position to vomit is induced. Not only is the effect of taking ingesta 
later in its development of the nausea, but that constantly existing does 
not culminate in efforts at vomiting, so frequently as in the more active 
grade of gastritis. Perhaps there is also, in nearly all the cases, a less 
intense burning quality to the pain, and more of a dull, heavy, oppressive 
feeling. These differences are simply what would naturally be inferred 
from the fact that the food being first taken into the stomach requires a 
little time to be passed through that organ into the duodenum, where it 
will come in contact with the inflamed surfaces. It is due also somewhat 
further to the fact, that the duodenal membrane is not apparently supplied 
as liberally with nerves of acute sensibility as the gastric membrane. 
Another difference consists in the fact, that the duodenal inflammations, 
whether acute or chronic, are liable to involve that portion of the mem- 
brane connected with the openings of the hepatic and pancreatic ducts, 
and sometimes to extension of the inflammatory process into the lining 
of thepe ducts by continuity, from the membrane in the duodenum. 
When this occurs the tumefaction of the membrane consequent upon the 
increased accumulation of blood, and of inflammatorj^ exudations into its 
texture will sometimes so far obstruct the flow of these fluids as to cause 
their accumulation in the ducts, and sometimes their reabsorption. This, 
so far as the pancreatic fluid is concerned, gives no alteration of color and 
consequently affords us but little opportunity for determining with certainty 
what part it plays in the symptoms of the patient. But the obstruction 
in the opening of the hepatic ducts preventing the free flow of bile into 
the intestine causes reabsorption from the over-full ramifications of the 
ducts in the lobules of the liver, and speedily produces yellowness of 
the conjunctiva of the eye and subsequently of the whole cutaneous 
surface, with a dark brownish hue of the urine, and all other phenomena 
which are usually included under the term jaundice. When inflammation, 
either acute, chronic, follicular, or ulcerative is restricted to the membrane 
lining the duodenum, it not only produces the same changes pathologically 
that we have described as taking place in parallel grades of inflammatory 
action in the mucous membrane of the stomach, but they are amenable to 
the same modes of treatment in all respects ; consequently, I need not 
repeat in reference to them what I have only just detailed as applicable 
to the inflammations in the stomach. There is, however, one form of in- 
flammation commencing in the duodenum, and giving rise to an 
assemblage of symptoms which most writers have included under the 
name, gastro-hepatic catarrh, which requires some notice. 

Duodeno- Hepatitis. — But my own observation, aided by one or two op- 
portunities for post-mortem examinations, has convinced me that nearly 
all these cases of disease commence as subacute inflammation of the 
membrane lining the duodenum, and extend by continuity into the hepatic 
ducts, often following that membrane to their ramifications in the central 
portion of the liver, and therefore meriting the name not of gastro-hepatic 
catarrh, but of duodeno-hepatic catarrh, or preferably duodeno-hepatitis. 
Attacks of this grade of inflammation are most apt to be met with during 
the early part of adult life, and almost invariably during the transition of 
the seasons, spring and autumn, coincident with the prevalence of cold, 
wet, sleety, and changeable weather. In some seasons during the months 
of October and November, and in others, though more rarely in March and 
April, I have met with so many of these cases as to constitute a moderate 
epidemic. Some cases are met with every autumn. They have seemed 



SYMPTOMS. 527 

to mo to originate almost wholly from the impression of cold, damp air, 
upon the cutaneous and pulmonary surfaces, restricting the exhalation of 
effete or waste matter through these outlets, and inducing, by reflex in- 
fluence in part, and in part by direct action of the retained effete mate- 
rials, irritation and congestion of the mucous membrane of the duodenum 
and hepatic ducts. That the chief cause is exposure to cold, damp, and 
frequent changes is rendered more evident from the fact that they not 
only occur at the seasons of the year when these conditions of the atmos- 
phere are predominant, but they occur far more frequently in the male 
than in the female, and among laboring men or those whose employments 
cause them to take free outdoor exposure. 

Symptoms. — The symptoms in these cases vary much in accordance 
with the degree of severity of the attacks. In the large majority of those 
that have come under my own observation, the first symptoms of which 
the patient complains, are a sense of heaviness, with an obscure feeling of 
soreness in the lower part of the epigastric region, and indifference to taking 
food, although in many instance's, after commencing to eat, a fair quantity 
is taken. Accompanying the local sj^mptoms are the general feelings of 
depression and indisposition to exertion. 

From half an hour to an hour after food is taken, the feeling of fullness 
in the abdomen is increased, and generally accompanied by a sense of 
nausea, which lasts usually one or two hours, but passes off till food is 
again taken. Accompanying these early symptoms, the urinary secretion 
is usually diminished, and redder than natural. In many oases there is a 
white thin coat upon the tongue, there is very slightly increased heat of 
skin, a little dry look of the lips, but the pulse is hardly disturbed from its 
natural frequency. The symptoms, however, increase, and in about three 
days from their commencement there will be a moderate general leverish- 
ness often accompanied by dull pains in the head and back; the skin becomes 
dryer than natural, pulse accelerated ten or twelve beats faster than normal, 
an increased coating upon the tongue, with still greater dryness in the mouth, 
and a more constant feeling of heaviness or weight, and some degree of 
tenderness to pressure over the region of the duodenum. This heavy 
weight or load, as the patients call it, is much increased after taking 
food, and is. usually accompanied by nausea, which is also uniformly 
increased by pressure over the epigastrium. In the more active class of 
cases, a little pressure with the hand will not only excite nausea, but at- 
tempts at vomiting; and after food is taken it is apt to be rejected by 
vomiting in from half to three quarters of an hour. Usually, the food 
thus ejected is more or less sour and mixed with some mucus. The bowels 
are usually moderately constipated, the urinary secretions still more scanty 
and higher colored than at first; not merely redder, but now tinged with 
a reddish yellow hue, from intermixture of the coloring matter of bile. 
Close examination at this time or a day later, will discover a yellow hue of 
the conjunctiva of the eye, often a bitter taste in the mouth, a feeling of 
dryness, and usually an entire loss of appetite. If the case is not inter- 
fered with by the end of a week after the patient begins to complain, in 
the large majority of cases the skin and eyes generally present a deep 
yellow color, and all the outward aspect of a full jaundiced condition from 
the retention and diffusion of the coloring matter of the bile, through all 
the tissues of the body. The urine now becomes dark brown, or yellow- 
ish brown, and in bad cases very scanty in quantity. The sense of heavi- 
ness and weight in the epigastrium, accompanied by some increased full- 
ness, is quite distressing to the patient and usually compels him to keep 
a recumbent or semi-recumbent position. Under proper hygienic regula- 



OZS DUODENO-HEPATITIS. 

tions and mild treatment, most of these cases reach the clim x of their 
severity in from seven to nine days; after which a very gradual improve- 
ment takes place, consisting in less distress on taking food, less disposi- 
tion to vomit, and an increased secretion of urine, with the disappearance 
of the moderate grade of feverishness that had existed previously, and a 
steady diminution of the yellow hue of the skin and conjunctiva of the 
eye, until in from two to three weeks the patient usually returns to his 
natural condition both in general feelings and in the color of the surface. 
Occasionally a case is met with of such a degree of severity that the local 
symptoms of fullness, tenderness to pressure, nausea and vomiting when 
anything is taken into the stomach, become more constant and distressing, 
especially after the first three or four days. 

The matters ejected by vomiting, aside from the food and drink which 
may be taken, are almost exclusively mucus, sometimes glairy and tena- 
cious, at other times more thin or serous. At first it may be tinged with 
the coloring matter of bile, but after the first twenty-four or forty-eight 
hours there will cease to be any yellow or greenish hue to the matters 
vomited, and if the bowels are moved the evacuations are uniformly of a 
whitish or clay color, exhibiting no traces of the coloring matter of bile. 
The skin and eyes become early intensely yellow, the urine more nearly 
the color of beer and much diminished in quantity. These more 
severe cases also present much drowsiness, dry lips, deficient mois- 
ture in the mouth, coated, and sometimes dry tongue. In three 
cases that came under my observation during one season when these 
attacks were sufficiently numerous to constitute an epidemic, before the 
end of the first week the urine was nearly suppressed, there being no 
more than five or six ounces discharged in twenty-four hours ; the patients 
hardly susceptible of being aroused from their stupor, pupils dilated, 
breathing slow and sometimes irregular, pulse soft, easily com- 
pressed, abdomen somewhat distended and tympanicic, frequent 
attempts at vomiting especially when anything was taken even of the 
blandest character. In one of these cases, about the middle of the 
second week of the progress of the disease, the patient being about six 
months advanced in pregnancy, uterine pains commenced and proceeded 
until the foetus and after-birth were both expelled, while the patient 
was so stupid apparently from the toxaemic effects of the retained 
elements of bile, that she was wholly unaware of what was taking place. 
No hemorrhage followed, and the uterus remained firmly contracted after 
the expulsion of its contents. But coincident with this, the secretion of 
urine became entirely suppressed, the use of the catheter finding none in 
the bladder. In about twelve hours after the expulsion of the foetus, the 
matters ejected by vomiting or rather by regurgitation, became dark 
grumous, resembling very much the peculiar vomit of yellow fever. The 
pulse failed rapidly, the extremities became cold ; and entire collapse and 
death followed on the second day after the expulsion of the foetus, or 
about nine days from the commencement of the disease. Another of the 
three to which I alluded was a female but not in a pregnant condition, and 
although during the second week the kidneys secreted no more than 
from two to six ounces in the twenty-four hours, and the patient remained 
so much stupefied as to be incapable of giving any answers to questions, 
with the extremities cold, pulse feeble, mouth entirely dry, skin more of a 
bronze than a yellow hue, abdomen somewhat tumid and tympanitic, 
nevertheless, after lying in this condition for three or four days, she 
began gradually to improve and finally recovered. 

The third case was a man in the middle period of life and was under 



ANATOMICAL CHANGES. 529 

the care of a neighboring physician. I saw him only in consultation 
during the last st;ige of the disease, when he presented symptoms almost 
identically the same as those of the other two patients just described, 
and the case terminated fatally about the end of the second week. In 
this case a post-mortem examination was permitted; the results of which 
I will mention when speaking of the pathological changes produced by 
this form of disease. The milder class of cases will, many of them, not 
show any jaundiced condition or diffusion of bile in the system until 
sometime during the second week after the commencement of the attack. 
The patient complains throughout the whole course of the disease only of 
dullness, indisposition to exertion, dryness, and bitterness of taste in the 
mouth, moderate constipation of the bowels, scanty and dark colored 
urine, indifference to nourishment, and a heavy, dull feeling in the lower 
part of the epigastric region, and some nausea. This inclination to nausea 
is uniformly increased by any pressure upon the part, the heaviness and 
nausea are usually also increased for two or three hours after any nourish- 
ment is taken into the stomach. In these milder cases there is seldom 
actual vomiting unless very decided errors are committed in allowing too 
much food and drink. During the first week the discharges from the 
bowels are tardy and lighter colored than natural; but if vomiting is pro- 
voked, there may be evidences of bile mixed with the matters vomited. 
But after the middle of the second week even in the mildest cases that 
have come under my observation, the conjunctiva becomes yellow with 
the coloring matter of bile, the urine becomes a peculiar brownish yellow, 
and there appears some degree of yellowness of th"* skin generally. This, 
however, is often only moderate, and continues only for a few days before 
it again begins to decline. Most of these mild cases will complete their 
whole course in from two to three weeks ending in entire recovery, often 
with but little other treatment than a judicious regulation of the patient's 
food and drink. 

Anatomical Changes. — The general symptoms which I have detailed 
as characterizing the commencement of the diseases grouped under the 
head of duodeno-hepatitis, are such as plainly to indicate an interference 
with the functions both of the duodenum and the liver, or rather 
the ducts of the liver. You will have noticed that all the earlier 
symptoms point to derangement of the functions of the duodenum, 
and that from two to eight or ten days elapse be'ore there 
are evidences of interference with the flow of bile. This is, of 
itself, sufficient to indicate that the disease commences in the mem- 
brane lining the duodenum, and extends subsequently to the ducts of 
the liver, or in some way involves an obstruction of these ducts, and that 
all the symptoms attributable to retention of bile are secondary in their 
relations. The fatal case to which I alluded, on which a post-mortem 
examination was made, presented no important symptoms of disease in 
any of the organs or structures of the body, except two or three limited 
patches of slight inflammatory injection of the membrane lining the 
lower part of the stomach, and the whole lining membrane of the duo- 
denum, and the hepatic ducts, up to their ramifications into the interior of 
the liver. 

In this case the entire mucous membrane of the duodenum was in- 
tensely injected, some portions of it of a dark brownish color, and much 
softened, and other portions of a brighter red and less impaired in texture. 
The membrane lining the common duct, and all the larger branches was also 
in a similar state of intense injection, with tumefaction sufficient to close 
up the duct, and render it impervious, or at least nearly so, to the passage 



530 DUODENOHEPATITIS. 

of bile. The gall-bladder was moderately distended with bile but nearly 
natural in colo ■, the central portion of the liver surrounding the entrance 
of the large vessels was tinged a paler more olive hue, slightly softened 
in texture, and apparently undergoing fatty degeneration. Nearly all 
of the smaller bile ducts, as they are connected with individual lobules of 
the liver, were distended with bile. The whole organ was moderately in- 
creased in size. No part of it had that injected condition of its vessels 
or exudations of an inflammatory character, corresponding with inflamma- 
tion of the structure of the liver. The inflammatory process was appar- 
ent^ limited to the mucous membrane lining the ducts and the whole of 
the duodenum with the limited patches which I have mentioned, in the 
stomach. The swelling and enlargement of the liver, and the changes 
which it presented, appear to be attributable more to the continued en- 
gorgement of the bile ducts, and consequent interference with the molecu- 
lar movements, than to any inflammation in the hepatic structures. The 
results of this examination, together with the clinical history of all this 
class of cases, render it obvious that the disease is essentially a mild grade 
of inflammation, involving primarily the mucous membrane of the duode- 
num, and sometimes limited to it; but in the large majority of instances 
entering enough into the hepatic duct to cause tumefaction and obstruc- 
tion to the flow of bile, thereby adding the phenomena of jaundice to 
those of the duodenal disease. It is very rare that cases of this kind ter- 
minate fatally. The only one directly under my own care thus terminat- 
ing, was the woman whose case I have already briefly described. 

Diagnosis. — The three conditions with which the disease u 'der consid- 
eration may be confounded, are a moderate degree of gastritis on the one 
hand, a torpid or inactive condition of the liver, allowing the elements of 
bile to accumulate in the blood, until more or less of a jaundiced hue is in- 
duced, and direct obstruction of the hepatic ducts, from biliary calculi, the 
pressure of tumors, or any other mechanical impediment. From the first 
of these it is distinguished chiefly from the fact, that there is much less 
sense of burning heat in the epigastrium, the increase of heaviness, pain 
and nausea, are decidedly later after taking food than in cases of gastritis; 
allof the symptoms are of a more dull and obscure character. If vomit- 
ing occurs, instead of occurring promptly after taking ingesta, as in gastritis, 
it is more generally from half an hour to an hour later. From the second, 
or true torpor of the liver, it may be distinguished by simply noting 
the order in which the symptoms are presented, namely: the occurrence 
of weight or heaviness in the lower part of the epigastrium, with no sen- 
sations of either tenderness, weight or fullness in the right hypochondriac 
region, as is generally the case when there is any failure in the secretory ac- 
tion of the liver, either from congestion or from any other mode of arrest- 
ing the action of the secreting cells. 

The distinction is further developed by the fact that in the duodenal 
affection there are symptoms of a feverish character, and it progresses 
more decidedly as an inflammatory affection, reaching its culmination 
usually within a few days; while simple torpor or inactivity of the liver 
is usually accompanied by no febrile phenomena, only an obscure feeling of 
heaviness or weight in the right hypochondrium, rarely any nausea, dis- 
position to vomit, or any sense of tenderness on pressure over the lower 
portion of the epigastric region. Then again, simple torpor of the liver, 
sufficient to prevent the evolution of the bile from the blood, allowing its 
elements to remain, is a very rare form of disease; so rare that 1 have met 
with very few unmistakable cases in the whole period of my practice. 
From primary obstruction of the hepatic ducts, either through formation 



PROGNOSIS. 531 

of biliary calculi, or other mechanical causes, the duodeno-hepatic disease 
is distinguished by the primary symptoms being located in the region of 
the duodenum rather than in the right margin of the epigastrium, and ex- 
tending farther to the right, and by the almost uniform absence of febrile 
symptoms in connection with the formation of biliary calculi. The latter 
are usually slow in their formation, causing no active disturbance of the 
functions of the stomach and duodenum, and often giving rise to no symp- 
toms which attract the attention of the patients until suddenly they are 
seized with pain, generally in the region of the gall-bladder, and which, 
in cases of much severity, after a period varying from an hour to one or 
two days, ceases as suddenly as it commenced, and leaves as a result 
more or less yellowness of the conjunctiva and of the skin, and a dark, 
reddish brown color of the urine, but at no time is it accompanied by febrile 
symptoms, or any other of the phenomena that I have described as be- 
longing to duodeno-hepatic disease. 

After the paroxysm of pain is passed, all the symptoms disappear, even 
the yellowness of the skin continues only two or three days, and the 
patient appears to be reasonably well until another paroxysm occurs, 
which may be in a few weeks, or not in as many months. Cases of 
mechanical obstruction produced by tumors or morbid growths in the 
abdomen are readily distinguished from cases of duodeno-hepatitis by the 
manifest presence of the tumors as felt through the abdominal walls. 
Yet, notwithstanding the apparent readiness with which the disease 
under consideration may be differentiated from either torpidity of the 
liver, or mechanical obstruction of the hepatic ducts, from the causes to 
which I have alluded, a large proportion of the cases are regarded by the 
patients as bilious attacks, and not infrequently the physician when 
called is also induced to regard the dull, heavy feelings of the patient, and 
more or less yellow appearance of the skin and eyes, as evidences of con- 
gestion, or inactivit}'- of the liver. I have known very many of this class 
of cases, that have been placed under active treatment for supposed 
hepatic congestion, and sometimes subjected to the action of a very in- 
jurious amount of cholagogues and purgatives, which, instead of pro- 
ducing the desired bilious evacuations from the bowels, only hastened 
the patient into a diarrhoea, from extension of the irritation to the mucous 
membrane of the lower bowels causing extreme prostration, from which 
recovery took place very slowly. 

Prognosis.— From what I have already said when speaking of the 
general course of the disease, and the almost uniform tendency to 
recovery, you will have already inferred, that, with the exception of very 
rare cases, the prognosis is favorable. In at least seventy-five per cent of 
all the cases that have come under my observation, simply the restriction 
of the patient to a very mild diet, gently opening the bowels once or 
twice with saline laxatives, and rest, recovery has taken place in from one 
to three weeks. Of the remaining twenty-five per cent, nearly all with 
judicious treatment aided by rest and proper regulation of the diet have 
also reached recovery in from two to four weeks. Very rarely the 
retention of the cholestrine and other elements of bile has caused an 
accumulation of these elements to such an extent as to produce fatal 
poisoning of the cerebral centers ; which is usually preceded by entire 
suppression of urine, and indeed, of almost all secretions. 

I have seen a few instances in which the disease, either from neglect 
or mismanagement in the early stage has assumed a chronic form and 
continued for several weeks, in one twelve weeks, and in four or five 
other cases, periods varying from eight to ten weeks. When it assumes 



532 DUODENO-HEPATITIS. 

a chronic form the patient usually becomes entirely free from any fever ur 
increased heat, but rather presents a cool skin, cold extremities, a pinched 
or haggard appearance of the face, deep yellow or bronzed hue of the 
skin and eyes, and almost always accompanied by an eruption of prurigo 
upon the surface, attended by the most intolerable itching. This latter 
symptom is often so troublesome to the patients that they complain of it 
more severely than of all the other symptoms of the disease. Throughout 
this protracted period in the chronic form, the heaviness and weight in 
the epigastrium continues, with obscure tenderness on pressure; the lat- 
ter almost invariably accompanied also by a sense of nausea. The bow- 
els are generally costive but free from tympanitis. The patients are 
mentally dull, despondent, and gloomy, usually but little disposed to take 
food, and always in from half to three quarters of an hour after taking it 
complain that it increases their sense of distress. Occasionally when they 
have taken a little more than usual, in from one to two hours it will be re- 
jected by vomiting. Almost invariably when vomiting thus occurs, there 
is more or less mucus with the matters ejected, while food appears only 
partially digested and sour. None of these chronic cases terminated fa- 
tally. 

Treatment. — If what I have stated in regard to the nature of these 
cases is true the first indication for treatment is obvious, namely: the 
adoption of such measures as are calculated directly to lessen the mor- 
bid sensitiveness and vascular fullness of the vessels in the mucous mem- 
brane of the duodenum. If this is done early and effectually, there will 
occur no obstruction to the flow of bile, and consequently no subsequent 
jaundice, and the patient will recover by the end of the first week from 
the beginning of the attack. But unfortunately, the great majority of 
patients will not seek for the services of a physician until the first three or 
four days have passed, and the disease has already entered more or less 
into the hepatic ducts. This does not alter the indication for treatment. 
For you will observe the obstruction here is from the inflammation and 
consequent tumefaction of the lining of the duct; and the only rational 
mode of removing the obstruction is by removing the inflammation itself. 
The retention of the coloring matter of bile and other elements, so far 
from being evidence that the liver is torpid, and affording indications for 
remedies to act especially upon the secreting function of that organ, are 
evidences of just the reverse. For the secretion is carried on with the 
usual activity, the absence of any appearance of bile in the evacuations, 
and its diffusion through the system, are evidences that while being se- 
creted with the proper activity, it fails to pass through its natural channels 
into the intestines, and is re-absorbed. Consequently, all remedies that 
are calculated to increase the secretion of bile, without at the same time 
removing the obstruction in the bile ducts, will only add to the amount 
re-absorbed and diffused through the system; and consequently to an 
increase of the jaundice. 

The treatment which I have found most efficient for these cases has 
usually been as follows : If, on inquiry, I find the bowels have not moved 
for the preceding twenty-four or forty-eight hours, I give the patient 
a sufficient quantity either of the liquid citrate of magnesia, the sulphate 
of magnesia, or the Rochelle salts, to procure a moderate movement of 
the bowels. This is done more for the purpose of freeing the alimentary 
canal from accumulations of faeces, than for any other purpose, although 
these saline remedies undoubtedly have some influence in directly deplet- 
ing, and thereby lessening the fullness of the vessels of the mucous mem- 
brane, as. well as to empty the bowels. If the bowels, however, have been 



TREATMENT. 533 

moved sufficiently either by medicines that the patient has taken, or spon- 
taneously, I do not give a laxative at the beginning, but place the patient 
directly upon the use of a powder composed of three decigrams (gr. v) 
of the compound powder, of opium and ipecacuanha (pulv. Dov.), and an 
equal quantity of nitrate of potassium. Sometimes I add to this six centi- 
grams (gr. i) of calomel, but more frequently it is omitted. If the latter is 
added, it is only to the first four doses. One of these powders is given 
every four hours, until from four to six have been taken. In the mean- 
time, the patient is kept at rest, taking only liquid nourishment, such as 
beef-tea, oatmeal gruel, sometimes milk, or milk with lime-water, and at 
the end of this time, I administer another mild saline laxative. In the 
large proportion of cases, the evacuations following this laxative will be 
freely colored with the presence of bile. If so, it is almost always the 
case, that all disagreeable symptoms are decidedly relieved. By giving 
one of the same powders morning and evening for two subsequent days, 
and a mild laxative when required, the patient will reach the beginning of 
convalescence. If there is no further suffering after taking food, if the 
secretions from the kidneys are natural, the skin moist, tongue clean, and 
in all respects, the patient is free from feelings of sickness except a cer- 
tain degree of debility and some yellowness, no more medication is usu- 
ally required, but simply judicious regulation of the diet, and caution 
about returning too soon to active mental and physical labor. 

But in some of the more severe cases, although the treatment is carried 
far enough to cause the operation of the saline laxative, after the 
exhibition of from four to six of the powders I have named, there 
will be no appearance of bile in the evacuations, and , only a mod- 
erate lessening of the fullness, heaviness, and distress in the epigastrium. 
If such is the case, instead of giving the powders subsequent to this 
every morning and evening, repeat them at the same intervals as at first, 
namely: once in four or five hours, putting at the same time fomentations 
over the epigastric region, either by poultices, or by cloths wet in warm 
water or in some warm narcotic infusion. In cases of more decided 
severity I apply a blister over the most tender part of the abdomen, and 
with very good results. After this, simply keeping the bowels soluble, so as 
to have them move once, or at most twice in the twenty-four hours, carefully 
guarding against excessive purging, and if the urine is still scanty, giving 
the mixture of liquor ammonia acetatis, and nitrous ether, in doses of a 
teaspoonful diluted with water, three or four times a day, will be sufficient 
to conduct the patient to convalescence. In the cases which have as- 
sumed a decided chronic form, there has been some difficulty in affording 
them relief. One of the most obstinate that came under my observation 
finally recovered under the continuous use, for three weeks, of a prescrip- 
tion containing muriate of ammonium, and bichloride of mercury, dis- 
solved in the S} T rup of licorice, in such proportions that in giving four 
cubic centimeters or a teaspoonful of the solution, the patient would get 
four decigrams (gr. vi) of the muriate of ammonium, and two milligrams 
(gr. 1-30) of the bichloride; this quantity was given three times a 
day. He had used a great variety of remedies, during the preceding 
two months, with but little advantage. 1 have used the same combination, 
in the same manner, in four or five other cases that assumed a chronic 
form, but of less duration than the one to which I alluded. In the major- 
ity of these, it produced also favorable results; but in two of them it 
added somewhat to the burning and irritation of the mucous membrane, 
which caused some nausea and subsequently vomiting. These two patients 
ultimately recovered under the influence of moderate doses of the sub-ni- 



534 ENTERITIS. 

trate of bismuth, bicarbonate of soda, and a small proportion of the com- 
pound powder of opium and ipecacuanha, with an occasional laxative to 
move the bowels. In some of these cases of a chronic character, counter- 
irritation by the application of the combination of croton oil, tincture of 
iodine, and ether, applied over the epigastrium appeared to do good. 



LECTURE LI II. 



Enteritis, Acute and Cnronic— Varieties, Causes, Symptoms, Anatomical changes, Diagnosis, Prog- 
nosis and 1 reatment. 

GENTLEMEN : I shall next direct your attention to the inflam- 
mations occurring in the small intestines under the general name of 
enteritis. The first section of the small intestine called jejunum is rarely 
involved in inflammation. The second section, called ileum, is much 
more frequently the seat of disease. Attacks of inflammation may be 
limited entirely to the mucous membrane or to the muscular and 
peritoneal coats; or they may involve all these structures at once. 
The inflammation appears to commence in the middle and lower section 
of the ileum, in proximity to theileo-ccecal junction more frequently than 
in the upper part. Sometimes it commences in, and may be restricted 
during its course to the ccecum, and the ileo-ccecal junction, and is then 
called typhlitis, to distinguish it from the more general inflammation of 
the ileum. In another class of cases, the inflammation either commences 
primarily or soon extends to, the areolar tissue exterior to the ccecum and 
ileo-ccelic junction causing tenderness, pain and swelling with more or less 
soreness directly above Poupart's ligament, in the right iliac fossa. Such 
cases are called peri-typhlitis. Attacks of inflammation in all parts of 
the small intestine occur more frequently in the warm seasons of the year, 
and in autumn, than in the winter and spring. They are met with, 
however, occasionally at all seasons of the year. They occur more 
frequently in children and youth, than during the adult period of life. 
They are especially rare in old age. Still, cases are met with at all 
periods of life, and perhaps with nearly equal ratio in both sexes. Under 
my own observation, however, more cases have occurred in males than in 
females. Aside from the influence of the seasons of the year, and that of 
age and sex, perhaps exposure to sudden and severe atmospheric changes, 
particularly to cold and wet, constitutes the most frequent exciting 
cause. In typhlitis, it has been supposed that the inflammation has its 
origin in the ccecum, or appendix vermiformis, as in many cases post- 
mortem examination has revealed the existence sometimes of hardened 
faeces, more frequently of such foreign bodies as cherry stones, apple 
seed, unbroken kernels of grain, that had been swallowed sometimes at a 
considerable time previously. In peri-typhlitis, the cause has been traced 
in some instances to the lodgment of similar bodies, primarily in the 
appendix vermiformis, which apparently became inflamed and ulcer- 
ated, thereby setting up inflammation in the areolar tissue immediately 
around it. 

/Symptoms. — As the word enteritis is applicable alike to inflammation 
in any of the coats of the intestine, and as the symptoms vary much in 
accordance with the variations in the particular seat of disease, it becomes 



SYMPTOMS. 535 

necessary to describe the symptoms of inflammation of the mucous mem- 
brane, as distinct from those of inflammation of the muscular and 
peritoneal structures. For the purpose of exactness, or to avoid being 
misunderstood, I shall, denominate such cases as mucous enteritis,' those 
involving the muscular coat, as muscular or rheumatic enteritis, and when 
primarily located in the peritoneal covering of the intestines, as peritoneal 
enteritis. The symptoms of acute and subacute mucous enteritis 
usually commence gradually, consisting at first of a sense of heat, 
irregular peristaltic motion in the abdomen, slight feelings of soreness 
particularly on sudden motion of the body, or from the jar of walking. 
The sense of soreness, however, and tenderness on pressure in the begin- 
ning of this form of inflammation is usually slight. In the course of 
twelve or twenty-four hours there will be more or less general febrile 
movements, indicated by a moderately increased heat and dryness of the 
skin, and acceleration of the pulse, which is at the same time, usually firm 
under the finger, small and corded. The respirations are usually slightly 
accelerated, the pain in the abdomen increased, especially the burning or 
sense of heat, and the temperature of the abdomen externally appears 
higher than the rest of the body and extremities. The pain is seldom of 
an acute lancinating character, but dull and accompanied by frequent, 
irregular peristaltic movements of the intestines, these movements being 
often accompanied by pains, which are called griping, but momentary in 
their duration, and usually accompanied by a sensation as though the 
bowels would move. During the iast part of the first twenty-four hours, 
intestinal evacuations begin to occur. The first one or two passages will 
usually be fsecal, the first firm or consistent, the second softer, but yet 
not fluid. From this time the intestinal evacuations occur more frequently, 
varying from three to six or eight times a day, usually nearly fluid in 
consistence, sometimes of a gray or ash color, more frequently brownish, 
or reddish brown. Not infrequently the discharges contain little specks 
of a whitish substance, consisting of flakes of lymph, and detached 
epithelium. In most instances, each evacuation from the bowels is pre- 
ceded for a minute or two by irregular abdominal pains. These vary 
very much in severity in different cases. Sometimes they are almost 
entirely absent. The tongue and mouth are less moist than natural, the 
first usually covered or partially covered with a whitish coat in the 
beginning, the tip and edges looking slightly redder than natural. If the 
disease continues three or four days without interference, the pulse 
becomes smaller, softer and more frequent, the extremities cooler, but 
the abdomen and trunk of the body maintain a higher temperature, the 
mouth is more dry, the lips looking parched and a little thin; countenance 
shrunken, and often a strip in the middle of the tongue, dry and more 
brown. 

In some instances the abdomen becomes somewhat tympanitic, but 
more frequently not fuller than natural, and exhibits but little gaseous 
distension or tympanitis on percussion. To the touch or pressure there 
is almost invariably more or less tenderness. In mild cases the symp- 
toms consist of a moderate grade of general fever, accompanied by 
diarrhceal discharges, continuing with but little change from five to seven 
days, when if the patient has simply been at rest, abstaining from promis- 
cuous food, taking only bland and light nourishment, the symptoms begin 
to abate, the discharges become less frequent, the sense of heat in the 
abdomen and dryness of the mouth diminish, the tongue becomes more 
moist, and free from coating, and the urinary secretion returns more 
nearly to its natural condition, and by the middle of the second week the 



536 ENTERITIS. 

patient is convalescent. The bowels either remain entirely quiet, or if 
discharges take place, they present a natural appearance. It is thus that 
very many cases of moderate mucous enteritis, every summer, run their 
course and terminate favorably in from seven to ten days, with little 
other treatment than simple rest, and proper regulation of the ingesta. 
But in more severe cases of an acute character, the symptoms at the end 
of the first week are liable to become aggravated. The tongue becomes 
more completely dry, the abdomen moderately tympanitic, more sensitive 
and tender on pressure, the discharges dark brown, and sometimes mixed 
with blood, the little masses of mucus occasionally contain sufficient 
blood to tinge the whole discharge of a distinctly reddish hue; pulse 
becomes soft, quicK and irregular, the extremities cold and a little leaden 
or purplish hue, the eyes sunken, lips thin and retracted, a tendency for 
sordes to gather along the edges of the lips and exposed parts of the teeth, 
the patient's mind is often wandering, causing especially muttering in sleep; 
when left alone, he is inclined to be drowsy and dull, and the urine very 
scanty. If no change is made by treatment such a case will sometimes 
proceed rapidly from this point to complete collapse and death by exhaus- 
tion. The patient continues simply to grow weak, the extremities colder, 
pulse feebler, the mind more dull or wandering, until the sphincters relax, 
the discharges become involuntary, the chin drops, tongue falls back, breath 
becomes more and more irregular and obstructed by the relaxation of the 
muscles of the pharynx, and death ensues from pure asthenia. Within 
my own observation such results are of rare occurrence, and confined 
almost entirely to those patients who are living in bad sanitary surround- 
ings, and failing to procure either reasonably good nursing or any suitable 
medical attendance. Occasionally during the highest temperature of 
summer, attacks will occur among children especially, having much the 
appearance of cholera morbus and cholera infantum at the outset, the 
more violent symptoms of which soon abate, leaving a genuine mucous 
enteritis which sometimes progresses rapidly to a fatal termination. 
Between the two classes of cases I have described, one tending spontane- 
ously to recovery, the other sometimes proceeding to a fatal result, you 
will meet with a large number presenting symptoms of a severe character 
during the first week of their progress, abating during the first half of 
the second week as though convalescence was approaching, and at the end 
of three weeks, nearly all the more active symptoms will have disappeared, 
leaving the bowels still loose, with considerable impairment of flesh and 
strength, but not so much as to prevent the patients from being up some 
each day. These are cases commencing as acute or subacute inflamma- 
tion, and which terminate, not in recovery, but in the chronic form of the 
disease. They are liable to continue an indefinite period of time. Some 
of them under favorable circumstances, after continuing three or four 
weeks, gradually improve until they end in recovery. Others, however, 
after continuing nearly stationery for three or four weeks, during which 
the patients are able to be up and dressed, again begin to retrograde; 
losing flesh and appetite,the discharges becoming more frequent, sometimes 
giving indications of intermixture of muco-purulent material in the first 
portion of the evacuations, either with or without a tinge of blood, a re- 
newal of moderately increased temperature, especially of the abdomen, 
small weak pulse, cold extremities, rather haggard expression of counte- 
nance, and finally fatal exhaustion. Intermediate between those that thus 
run to a fatal termination, and those continuing five and six weeks and 
ending spontaneously in recovery, there is still a class that maintain a 
moderate degree of diarrhoea, sufficient to continue the impairment of 



ANATOMICAL CHANGES. 537 

strength and prevent a return to the active duties of life, and yet not 
sufficient to cause any rapid degree of exhaustion, and in which condition 
the patients may remain one, two or more years, with but little change 
from month to month. The symptoms and progress of these cases as I 
have stated them, represent the natural progress of thn disease when not 
actively interfered with by judicious medication. When the latter is 
brought to the aid of the patient, there are very few cases of those that 
have assumed a decidedly chronic form, but that may be conducted to an 
ultimate recovery. 

Anatomical Changes. — The anatomical changes which take place dur- 
ing the progress of acute and subacute mucous enteritis, correspond in 
all respects with the changes that 1 have already described as taking 
place in the mucous membrane of the stomach and duodenum. In the first 
staged, there is intense congestion, causing redness and more or less tume- 
faction of the membrane, with subsequent increase as the disease progress- 
es, the redness changing more to a brown or dark hue in many places, with 
softening or impairment of the texture and detachment of much of the 
epithelial layer, leaving abrasions or superficial ulcerations. In the sub- 
acute cases and especially those that run a more protracted course, exuda- 
tion of liquor sanguinis, or plastic material of the blood, takes place, into 
the sub-mucous or connective tissue, aud into the texture of the membrane 
as well as upon the free surfaces. In such cases, instead of softening of the 
membrane it becomes more thickened and hardened, but generally presents 
the same disturbance of the epithelial layer, and the same marked abra- 
sions upon the surfaces as in the more acute cases. When the disease as- 
sumes a chronic form, the diffused redness that accompanies the acute 
and subacute stages subsides over the larger part of the membrane, 
allowing it to return to a more natural color and appearance; only 
patches remain red, thickened, more or less hardened in texture, 
and pretty uniformly present distinct and ' deep ulcerations upon 
their surface. Some of these ulcers in cases of long continuance 
have been found to extend more deeply into the coats of the 
intestines, destroying not only the mucous membrane, and sub- 
mucous areolar tissue, but also the muscular coat to the peritoneum. 
Sometimes, though quite rarely, the peritoneum itself is perforated, 
bringing on acute general peritonitis as the immediate cause of the death of 
the patient. In many of these cases, both of a chronic and acute form, where 
death has resulted, there is a more or less injected and reddened con- 
dition of the peritoneal membrane over those parts of the intestine that 
are most involved in the disease. The changes which I have 
described will explain to you the progress of those cases that commence 
in the acute form and terminate in the chronic. The subsidence of the 
more severe symptoms marking the termination of the acute stage, is the 
time w T hen inflammation undergoes resolution and disappears from a large 
portion of the mucous membrane; leaving only limited patches where, 
from the thickening and induration, and more decided ulcerative changes 
of the surface, resolution can not take place as readily; and in consequence 
of this, the discharges in their milder form are continued after the gen- 
eral symptoms have undergone the improvement I have mentioned. In 
many of the cases, these patches continue slowly to improve, the abra- 
sions are repaired, while the exudative material is removed by disintegra- 
tion and absorption, and convalescence is reached in from four to five weeks, 
while in those cases that linger longer, little or no reparative action 
takes place in the inflamed and ulcerated patches, the ulcerations tend- 
ing to increase instead of cicatrizing. It is thus they run a more protract- 
ed course and the patients ultimately die from exhaustion. 



538 ENTERITIS. 

Diagnosis. — Mucous enteritis presents symptoms, as you will have no- 
ticed, sufficiently characteristic to distinguish it from nearly all other af- 
fections of the alimentary canal. From typhoid fever it is distinguished 
by the well marked prodromic or forming stage of the latter, followed as 
it usually is by a progressive development of fever, and rise of tempera- 
ture day by day, neither of which correspond with the beginning and 
progress of simple enteritis. Cases of the latter have none of the dull heavy 
expression of countenance, suffused flush of the face, and steadily' in- 
creasing temperature that belongs to the general fever. And during its 
subsequent progress the dry bronchial rales so generally present in the 
second stige of the typhoid disease are absent, as are also the rose colored 
spots upon the cutaneous surface. From dysentery or inflammation of the 
colon it is distinguished by the lower degree of fever, the less frequent 
and painful character of the discharges, and the less intermixture of 
mucus and blood with the evacuations. From peritonitis, either of that 
part of the peritoneum covering the intestines, or lining the abdominal 
parietes, mucous enteritis is distinguished by the lower grade of fever and 
especially by the absence of lancinating, sharp pains, excessive tenderness 
to pressure or to any free motions of the body, and of early and decided 
distension of the abdomen. Of the prognosis in mucous enteritis in its 
different degrees of severity, I have already spoken sufficiently when 
giving its clinical history. 

Treatment. — The leading objects to be accomplished in the treatment of 
mucous enteritis are, to directly diminish the morbid sensitiveness of the 
mucous membrane, lessen the frequency of the discharges, and promote 
the natural eliminations from the skin and kidneys. Cases may be met 
with, though they are certainly rare, in which sufficient enteric irritation 
exists to produce more or less diarrhceal discharges, and yet the first 
part of the ileum remain filled with consistent or hardened faeces. If 
such a case should present itself, it is evident that a moderate movement 
of the bowels by such laxatives as would be likely to produce the least 
griping or local irritation in the inflamed parts, should constitute the first 
item in the treatment. Experience has shown that the faeces very rarely 
accumulate and remain stationery in the upper part of the ileum or any 
part of the jejunum. Indeed, the contents of the bowels rarely become 
consistent until they have passed below the middle portion of the ileum; 
and I have no recollection of ever seeing a case of mucous enteritis, in 
which I could detect, either from the history of the case, or from the con- 
dition of the abdomen, the retention of hard faeces in any part of the ali- 
mentary canal. And I am fully satisfied that the practice of many, to 
commence the treatment by a saline laxative, merely for the purpose of 
being sure that the contents of the bowels have been removed, is calcu- 
lated to do more harm than good. I pretty uniformly prescribe, 
first, a combination of some anodyne with an alterant, and give sufficient 
to first place the patient at ease from pain, and the alimentary canal in a 
condition of quietude, with a view of keeping it at rest, for at least eight- 
een or twenty- four hours. At the same time remedies are given for the 
purpose of gently promoting the action of the skin and kidneys. 

For all these purposes I have generally directed a powder composed of 
pulverized opium six centigrams (gr. i), pulverized ipecac uanha, one to two 
decigrams (gr. i to iii ), mild chloride of mercury six centigrams ( gr. i) 
to be given every three hours; and an equal mixture of liquor am- 
monii acetatis and nitrous ether, of which four cubic centimeters 
(fl 3i ) are given diluted with a little water, between each of the pow- 
ders. The latter will usually promote the action of the kidneys and skin, 



TREATMENT. 539 

while the former will control the intestinal evacuations and allay the pain, 
to such an extent, that in most cases, at the end of twenty-four hours, the 
patient is found quiet, often inclined to sleep, with the abdomen nearly 
free from tenderness, the skin moist, the pulse a little quicker than nat- 
ural, and the temperature one or two degrees above the natural standard. 
If this be the case I discontinue the further use of the powders, and 
simply leave the patient upon the use of the liquid preparation, 
once in three hours until eighteen hours more have passed, when if spon- 
taneous evacuations from the bowels do not occur, I promote a movement 
by an enema of warm water; or if this can not be conveniently used, I give 
a mild dose of sulphate of magnesia or Rochelle salts, aiming to give only 
enough to procure one or two evacuations : and always leaving instruc- 
tions to give the patient either three or five decigrams ( gr. v to viii) 
of the compound powder of opium and ipecacuanha, or its equivalent of 
some other opiate, as soon as the bowels have been moved the second 
time, if the discharges are free, or the third time if they are only moder- 
ate. The anodyne is to be repeated every lime the bowels move subse- 
quently, until they again become quiet. By such a course of treatment, 
accompanied by entire rest of the patient in a recumbent position, and 
restriction to bland, simple nourishment, such as lime water and milk, very 
thin wheat Hour and milk gruel, sometimes beef tea, or mutton, and chick- 
en broth in small quantities; the use of cold mucilaginous drinks, also lim- 
ited in quantity, or if the patient be very thirsty during the early part of 
the treatment, allowing bits of ice to be used instead of much drink, in near- 
ly all cases that come under treatment in the early stage, the disease is arrest- 
ed, the symptoms of inflammation rapidly disappearing, and the patient be- 
coming convalescent in from three to five days. But if the disease has 
been in progress longer before it has come under observation, having al- 
ready passed, in the acute cases, either to the stage of softening with more 
or less abrasion of the membrane, or in those of a milder grade to the 
commencement of the chronic stage, it is not possible to procure so prompt 
and early an arrest of the disease: and such remedies must be chosen for 
further treatment, as are calculated to procure, in addition to the necessary 
anodyne and alterative influence, an effect upon the capillary vessels of 
the mucous membrane, different from that of mere astringency. 

For this purpose, I have found no combination of remedies better, in 
the majority of cases, than the emulsion, containing oil of turpentine, 
tincture of opium, gum arabic and sugar. The formula I have generally 
used is the same that I have mentioned, when speaking of the treatment 
of the middle and advanced stages of typhoid fever, and consists of the 
oil of turpentine twelve cubic centimeters (fl. Z'ni), oil of wintergreen 
two cubic centimeters (fl. 3ss), tincture of opium fifteen cubic centimeters 
(fl. 3iv), pulverized gum arabic and white sugar, each twenty 
grams (3 V ), rubbed well together, with the addition of water, 
one hundred and twenty cubic centimeters (fl. |iv). If the in- 
gredients are well mixed, they make a uniform or homogeneous 
emulsion, of which four cubic centimeters (fl. 3i) may be given at a dose, 
and repeated every four or six hours, according to the frequency of the 
evacuations, or the degree of quieting effect that is desired. If the urine 
remains scanty and the skin dry, the patient may take suitable doses of 
an equal mixture of liquor ammonii acetatis, and nitrous ether, between 
each of the doses of the emulsion. Under the influence of these remedies, 
nearly all the cases will improve regularly from day to day until the 
evacuations from the bowels become natural. When this occurs, the 
emulsion should be suspended, allowing only the diaphoretic mixture to 



540 ENTERITIS. 

be continued until convalescence is complete. If, during the treatment, 
the patient has been allowed little or no ingesta, but the wheat flour and 
milk gruel in small quantities frequently repeated, alternated sometimes 
with animal broths, such as beef tea, it will be found almost uniformly, 
that the symptoms of the inflammation of the mucous membrane subside, 
the discharges become natural, the febrile symptoms disappear, the tongue 
becomes clean and the patient is convalescent, in from four to six days. 
Occasionally you may meet with a case of this variety of inflammation 
of the membrane lining the ileum, in which the turpentine and laudanum 
emulsion will not be tolerated by the stomach. In such instances I have 
found a pill composed of carbolic acid fifteen milligrams (gr. ^), pul- 
verized ipecac, thirteen centigrams (gr. ii), pulverized opium six cen- 
tigrams (gr. i), a good substitute for the emulsion, giving one pill 
under the same circumstances, and with the same frequency, that 
the doses of the emulsion were recommended, and they have rarely 
produced either nausea, or any unpleasant symptoms. On the 
contrary, they have been followed by a steady lessening of the 
pain and restlessness, and the discharges have improved in their number, 
and in their quality, until in a few days convalescence was established. 
When inflammation in the ileum assumes a chronic form, either as the 
sequel of an acute attack, or primarily, it is seldom advantageous or 
necessary to give the patient alterative doses of the mercurials in con- 
nection with the opium, as I have stated in the beginning of the acute 
form of the disease. The greater part of the cases that have come under 
my observation, have either resulted from severe attacks of a more acute 
character, or have followed as the sequel of typhoid or typho-malarial 
fever. During the progress of the war for the suppression of the rebellion, 
when there were large numbers of soldiers, who were more or less under 
the influence of causes productive of diarrhoeas, dysenteries, typhoid fever, 
and scorbutus, there occurred many cases of the most severe and pro- 
tracted form of chronic diarrhoea as the sequel of attacks of acute general 
diseases. Many of the cases belonging to the two first classes that I 
have mentioned, yielded readily to the proper regulation of the diet, and 
the use of the turpentine and laudanum emulsion, or the pills of carbolic 
acid, ipecac, and opium; only being careful to adjust the frequency of the 
doses to the degree of frequency of the discharges. In most instances 
it is sufficient to give four doses of either of these prescriptions in the 
twenty-four hours. There are some eases in which a prescription 
containing aromatic sulphuric acid, sulphate of magnesia, and tincture of 
opium, each four cubic centimeters (fl. 31), to thirty cubic centimeters 
(fl. |i) of water, given to adults in doses of four cubic centimeters (fl. 3i)> 
will be found equally efficient with either of the other prescriptions that 
I have named, and may be given more freely to such cases as are inclined 
to secondary nausea from the effects of opiates. The cases that follow 
typhoid fever are mostly dependent on the ulcerations of Peyer's glands, 
which have remained after the subsidence of the general fever. It is 
particularly in this class of cases that the nitrate of silver is to be re- 
garded as a valuable remedy. I have used it in many of the cases in 
the form of a pill, usually in doses of two centigrams (gr. -J), combined 
with six centigrams (gr. i) of opium, at first; but when the discharges 
were held more in check, I have reduced the opium to half that quantity. 
A pill containing these ingredients may be given, at first, every four 
hours. If the effect is favorable and some relief is obtained, the time can 
be subsequently extended to six hours, or even to eight hours. It is an 
object of importance, in these cases to regulate the diet of the patient. 



TREATMENT. 541 

The principle on which the diet should be regulated, is that of using such 
articles of food as will be sufficient in their composition to afford the 
patient the elements necessary to give complete nutrition, and in a form 
to be taken up as perfectly as possible in the stomach and first part of 
the alimentary canal, leaving the least possible residue to pass through 
the middle and lower bowels. 

In the great majority of cases, I have been able to find nothing that an- 
swers the purpose better than well prepared wheat flour and milk gruel. 
Sometimes oatmeal gruel, soft boiled rice and arrow-root, with moderate 
quantities of the animal broths, will be well borne, and may be used to a 
limited extent alternately with the flour and milk. But every time this 
class of patients indulge in taking promiscuously the coarser articles of 
food, the discharges become more irequent, with more pains in the abdo- 
men and an aggravation of all the symptoms. That class of cases, which 
I met with, chiefly during and a few years subsequent to the war, 
among the soldiers, presented some conditions that were different from 
ordinary chronic diarrhoeas. The patients pretty uniformly presented 
a very pale, bloodless or anaemic aspect; a clean state of the tongue, 
frequently a slightly cedematous condition of the feet and ankles, a very 
variable state of the appetite, and a pretty uniform increase of the peri- 
staltic motion and discharges soon after eating. Very generally these dis- 
charges were thin, reddish brown, or of a pale ash gray color. In most in- 
stances if the intestinal discharges were allowed to stand a little time in the 
vessel and the thinner part poured off, the thicker part in the bottom would 
contain small masses of mucus and specks of red blood, with more or less 
muco-purulent material. But this was not present in all cases. The habit 
of evacuating the bowels speedily after taking food seemed to keep the in- 
testines habitually empty. And, I observed, very uniformly, that whenever 
remedies were administered sufficient to arrest peristaltic motion, even for 
eighteen or twenty-four hours, the patients became very uneasy from the 
sense of distension or undue fullness of the abdomen, creating the 
idea that the discharges had been stopped too suddenly. This dis- 
agreeable sense of fullness was not, by any means, accompanied by an 
actual fullness. In very many of them there was no distension of the ab- 
domen, but rather a lank condition and yet the sensation of the patient 
was that of overfullness. Similar results almost invariably followed the 
use of the more astringent class of remedies in connection with opiates. 
And, if the restraining influence of the opium and astringents was contin- 
ued for thirty- six or forty-eight hours, no decided absorption of the con- 
tents of the bowels took place, but increased discharges occurred as soon 
as the effect of the medicine had ceased — the quantity being propor- 
tioned to the length of time they had remained quiet. 

Very few of this class of patients were benefited permanently, by any 
variety or combination of astringents and anodynes that I could devise. 
Some of them were benefited and ultimately cured by the careful 
regulation of their diet, and the protracted use of the nitrate of silver and 
opium pill; usually given at first four times in twenty-four hours diminish- 
ing the number according to the improvement that took place. A larger 
number, however, were benefited, and some of them ultimately cured, by 
using a powder composed of sub-nitrate of bismuth, three decigrams 
(gr. v), sub-carbonate of iron thirteen centigrams (gr. ii), and pulver- 
ized opium six centigrams (gr. i), usually given just before each meal 
and at bed-time, diminishing the number according to the degree of 
restraining effect produced. It was during the time that these soldiers 
were returning from the army with this form of diarrhoea and coming 



542 TYPHIL1TIS. 

frequently under my observation, that I was led to use bromine as a 
remedy in their treatment. It was first suggested to me by a medical 
officer in charge of the military hospital at Rock Island during a visit to 
that encampment, and I found it a very valuable remedy in many of this 
class of cases, as well as in cases of chronic dysentery originating under 
similar circumstances. The formula that I then used was bromine one 
cubic centimeter (min. xv), bromide of potassium twelve grams (3iii), 
distilled water one hundred and twenty cubic centimeters (fl. §iv), of 
which four cubic centimeters (fl. 3i), were given (further diluted with 
water at the time of administration) four times a day. This remedy uniform- 
ly caused an alteration in the color of the passages, to a bright yellow, 
and usually was followed by a gradual diminution in their number, with 
increase of consistency, until in from one to two weeks some cases of long 
standing were brought very nearly to a natural condition. The greatest 
objection to the remedy is the extreme pungency of the bromine, and the 
difficulty of concealing it sufficiently to prevent its being annoying to the 
patient during its administration. 

Typhlitis. — Owing probably to the greater tendency of faeces, and, 
perhaps, of foreign bodies or indigestible substances to accumulate in the 
caecum, until they become sources of irritation, inflammation of limited 
extent has been found to occur more frequently in that part of the in- 
testine and in the ileo-caecal junction, than in any other. When it has 
been thus limited, it manifests itself by pains and soreness in the right 
iliac region, and has been termed typhlitis to distinguish it from the more 
general inflammation of the mucous membrane of the ileum. But the con- 
sequences of inflammation here, in all its different grades, are the same as 
in any other part of the membrane, and it requires no difference in its 
management. When the patient is attacked with symptoms pointing to 
inflammation in this particular place, more careful examination should be 
made in reference to the evidences of retained faecal accumulations, in the 
caecum. It is by no means always the case that such accumulations 
exist. A majority of those that have come under my care, neither on 
close examination by palpation, nor inquiry into the nature, amount or 
degree of faecal evacuations previous to the commencement of the pain, 
have indicated the existence of any accumulation whatever. But when 
it is evident that either hardened faeces, or other substances exist there, 
it is best to commence treatment by using large enemas, filling the 
rectum well with a view of inviting freer evacuations from the bowels. 
If you begin by giving physic by the mouth and thus establish 
increased peristaltic motion above, it is liable to be followed by 
greatly increased pain, and sometimes, the establishment of irregular con- 
traction of the circular fibers of the intestine, thereby obstructing the 
further motions of the bowels, instead of facilitating the evacuations that 
are desired. 

Having thus formed an obstruction, all further administration of med- 
icines by the mouth are usually followed by troublesome vomiting, and a 
more rapid increase of all the local symptoms of inflammation, until either 
the patient becomes thoroughly prostrated, or symptoms closely resem- 
bling invagination supervene. Such results can almost always be avoided 
by relying mainly upon the remedies used as enemas to invite 
evacuations, while those administered by the mouth are decidedly 
soothing or anodyne in their iufluence, and on local applications of an 
anodyne character, such as cloths wet in warm narcotic infusions. In a 
few instances of this kind where the local pain in the ileum and the ten- 



PERITYPHLITIS. 543 

derness on pressure, with some tumefaction of the part, indicated decided 
inflammation, the pains were paroxysmal and severe, and the movements of 
the bowels entirely arrested, although evacuations had been free up to the 
time of commencement of the attack, thereby showing that there was no 
injurious retention of feces. Yet the administration of medicines by the 
mouth, of a laxative character, was followed by vomiting, until the sever- 
itv of the symptoms created decided alarm, and apprehension of invagi- 
nation, or some permanent intestinal obstruction. I have found very 
gratifying relief by the administration of enemas containing hydrate of 
chloral and belladonna. Fifteen decigrams (gr. xxiv) of the hydrate 
of chloral with fifteen cubic decimeters (min. xxiv) of the tincture of 
belladonna, suspended in about one hundred and twenty cubic centime- 
ters (n. 3iv) of milk-warm water may be introduced into the rectum as an 
enema, with instructions to the patient to retain it as long as practicable. 
If retained, it will be generally followed within half an hour by a decided 
sense of relief from the pain the patient has been suffering, and more or 
less disposition to sleep. This relief from pain and tendency to rest has, 
in some instances where I have used it, continued from two to three hours. 
When the patient has again begun to complain of a return of the 
paroxysms of pain and uneasiness the enema has been repeated. In one 
instance, the second enema being retained, no further vomiting nor pain 
was suffered for twelve succeeding hours; but the patient's pupils became 
dilated, mouth somewhat dry, and face a little flushed from the effects of 
the belladonna. At the end of that time two or three fascal evacuations 
occurred from the bowels, followed by a very moderate degree of griping 
pains and increased restlessness. Enemas containing half the quantity 
of chloral and belladonna were given, with instructions to repeat them 
at intervals, once in every six or eight hours, if pain should return suffi- 
cient to require their use. During the succeeding twenty- four hours a 
number of these smaller enemas were used, followed by moderate evac- 
uations from the bowels, and a rapid subsidence of all the inflammatory 
symptoms. For mention of several cases of a similar character treated 
cniefly by the use of enemas of chloral and belladonna, I may refer you 
to a small volume of " Clinical Lectures on Various Important Dis- 
eases," * written by me a few years ago. 

Perityphlitis. — In the same location where typhlitis is manifested, we 
meet with cases, not infrequently, in which patients are attacked rather 
suddenly with more or less acute pain in the ileum, usually just above 
Poupart's ligament, sometimes extending higher up in the direction of the 
ascending colon or centering in the lower part of the iliac region. The 
pain is usually acute and paroxysmal, accompanied by manifest tenderness 
to pressure externally, and within twelve to eighteen hours, more or less 
tumefaction or swelling in the part. Sometimes at the commencement of 
the symptoms, the patient will have one or two evacuations from the bow- 
els, not unnatural in their character. Very generally, the bowels have 
been free from constipation, at least several days previously, and no diar- 
rhoea. The occurrence, however, of the pain, swelling, and tenderness to 
pressure in the iliac region is usually followed by an arrest of further in- 
testinal discharges. And if the patient is not relieved, in most instances 
the pain and swelling both continue to increase until they occupy one 
third of the lower section of the abdomen, and the distension becomes 
considerable, with distinct hardness, as well as tenderness over the cen- 
tral point in the region of the iliac fossa. Meantime, the patient has be- 
come restless, pulse quick, respiration more hurried, with almost constant 

* Second edition, pp. 129 to 134. 



541 PERITYPHLITIS. 

sense of nausea and prompt vomiting of everything that he has taken in 
the form of drink or medicine. At first the matters vomited are simply 
the contents of the stomach, sometimes tinged with the coloring matter 
of bile, either yellow or green, and more or less bitter to the taste. Sub- 
sequently, they become more decidedly of a greenish hue, acid taste; and 
if the case continues two or three days without relief, the abdomen be- 
comes largely distended, as if peritoneal inflammation had extended over 
the whole surface of that membrane. The pulse becomes uniformly small, 
weak and quick, the extremities cold, surface bathed in clammy sweats, 
the eyes more or less sunken, the mind frequently wandering, dull and 
despondent; vomiting and regurgitation from the stomach of a dark 
grumous fluid takes place; and at a little later period, entire collapse and 
death follow. In. many cases, however, even with but little treatment 
during the first two days while accompanied by the symptoms I have men- 
tioned, before extreme prostration and extension of the symptoms of peri- 
tonitis over the abdomen occur, spontaneous evacuations take place from 
the bowels, and most frequently go to the extent of becoming thin 
diarrhceal discharges: after which the tumefaction gradually diminishes, the 
tenderness also abates, the pulse improves, and in three or four days the 
patient has reached a condition of convalescence. In the greater 
proportion of these cases, the latter result will be reached, if they are 
properly treated from the commencement of the attack. But there is an 
intermediate class of cases, between those that go directly on to entire 
collapse and death, and those which recover, either spontaneously, or by 
the aid of treatment, in which about the end of the first week of their 
progress, the general tumefaction of the abdomen ceases, the increase of 
febrile heat gradually diminishes, some evacuations take place from the 
bowels from day to day, but there remains, notwithstanding, a distinct 
well defined tumefaction over the iliac region, more or less hard and tender 
to pressure, and in a few days more, there is found to be evidences of 
deep-seated suppuration. 

The suppurative process now continues, and the patient remains as in 
any other case of suppurative inflammation, emaciating more or less rapidly, 
losing strength, and in some cases the symptoms are more of a hectic 
type of febrile movement, accompanied by sweats, particularly dur- 
ing the latter part of the night. Usually during the second week of 
the progress of the case, or at longest the third, the abscess which has 
formed will spontaneously open into the intestines and discharge 
its contents, which are easily recognized as pus, sometimes tinged with 
blood and accompanied by some fa3cal matter, in considerable quanti- 
ties. Such discharge is followed by direct subsidence of the swelling and 
fullness in the iliac region. In other cases the opening instead of being 
into the intestine will be into the peritoneal cavity, producing the 
usual rapid development of general peritonitis, extreme prostration, and 
speedy death. Instances are on record in which the abscess has found its 
way by the ulcerative process, into the bladder, discharging its contents 
through that viscus and urethra, with the urine. But, in the larger num- 
ber of cases, the tendency of the abscess is to the surface. Most gener- 
ally during the third week in the progress of the case fluctuation will be- 
come evident on proper examination, and by a free incision the matter 
may be discharged, and in most cases if the physician is sufficiently care- 
ful to give full drainage to the abscess, and subsequently, judicious anti- 
septic treatment with such nourishment and mild tonics as will sustain the 
general condition of the patient, a slow but pretty certain recovery takes 
place. These cases, which I have been describing, and which may pro- 



TREATMENT. 545 

coed to the various terminations mentioned, are termed in your books, 
perityphlitis. They consist essentially in an inflammation commencing 
exterior to the caecum, in the connective and areola tissue surrounding 
that portion of the intestine. The inflammation involves the coats of the 
intestine, sufficient to cause an arrest of peristaltic motion, and conse- 
quently, very generally an arrest, at least in the earlier stage, of the intes- 
tinal evacuations. And occasionally, it extends, as I have already men- 
tioned in speaking of the symptoms, to the mucous membrane, sufficient 
to develop moderate diarrhoeal discharges in the middle and latter stages 
of the progress of such cases. The inflammation, as you will infer from 
the symptoms I have described, in the milder cases terminates in resolu- 
tion, and simple disappearance of the exudative material, with no bad 
consequences, or sequelae, remaining. In other instances it occasions 
sufficient obstruction to the intestines, to wholly arrest the evacuations un- 
til vomiting becomes excessive, and prostration is induced to a degree that 
is dangerous to the life of the patient, and by the extension of the inflam- 
matory process to the peritoneum, may teiminate fatally; or, as in a 
large proportion of the cases is the fact, instead of these results, the in- 
flammation in the areolar tissue proceeds to suppuration, the formation of 
an abscess, which may spontaneously break in any of the direc- 
tions I have mentioned, but most generally tends toward the surface, and 
consequently comes within the reach of the practitioner or surgeon, and 
if properly attended to, is capable of being relieved in time for the resto- 
ration of the patient. I have met with many of these cases of perityph- 
litis, but in only one instance under my own care has the disease pro- 
ceeded to a fatal termination. This was the case of a young man, attacked 
with the disease in the usual form, but who did not come under my care 
until the end of the first week of its progress, when suppuration had al- 
ready taken place. I proposed an early incision, but his own timidity and 
that of his mother caused it to be postponed from day to day, longer than 
was judicious. 

And, although at the end of the second week of its progress, it was 
opened and freely discharged its contents and for about one week 
progressed favorably with every prospect of recovery, yet at the end 
of that time, it was observed that the purulent discharge which had pre- 
viously been diminishing began to be more copious, assumed a slightly 
greenish hue and became offensive. In one or two days more faeces 
were found to be mixed with the pus that was discharging from the open- 
ing. From this time on faecal matter and gases passed with the pus from 
the abscess, and notwithstanding all the care we could give, the patient 
gradually emaciated, and after lingering three or four months he was re- 
moved to his home in Michigan, where he died from asthenia, with the 
fistulous opening still remaining. 

Treatment. — In the management of this class of cases, if you are called 
early, I must caution you against the common practice of commencing 
the treatment by the administration of active cathartics. I have known 
these cases to be very much aggravated, and early and excessive vomit- 
ing induced, followed by inflammation and swelling over a large part of the 
abdomen by the administration of cathartics to. force active and 
free evacuations from bowels. You must bear in mind, that inflammation 
commencing in the connective tissue, exterior to the coats of the intestine 
proper, has a strong tendency to induce rigidity or contraction of the cir- 
cular fibers of the muscular coat, and that such contraction pre- 
sents an obstacle to the passage of faeces, consequently all administra- 
tion of cathartics while such contraction remains only increases the peri- 
35 



546 PERITYPHLITIS. 

staltic action from above downward, greatly increasing the pain and add- 
ing to the danger that the contracted part will be forced into the uncon- 
ted part below, thereby commencing an invagination that would not 
otherwise have taken place. The bad results of the common practice of 
commencing the treatment of all such cases with a determined effort to 
evacuate the alimentary canal by cathartics, led me many years since to 
take an entirely different course, namely, to bring the patient as speedily 
as possible under a sufficient anodyne influence to place the whole of the 
upper part of the alimentary canal in a state of entire rest and relaxation. 
For this purpose the preparations of opium are of irreat service, and if they 
can be conjoined with any other remedies that may lessen their tendency 
to produce secondary nausea and vomiting, it will be better to order them 
so combined, and given in sufficient doses to produce positive relief to 
the pains, and repeated often enough to secure as complete rest for the 
patient as possible, for at least twenty-lour or thirty-six hours. Some aid 
may be obtained by keeping the parts covered externally with warm 
narcotic fomentations. After the patient has been kept at rest as fully 
as possible, until the soreness has much diminished. I usually administer 
enemas of sufficient quantity to fill the rectum well, consisting of warm 
water rendered a little stimulating by the addition of common salt or sul- 
phate of magnesia. If the first enema passes off without producing any 
faecal evacuations, after waiting about one hour. I order another. 

And it is very rare that I have had to repeat the enemas more than 
two or three times, before _rtting satisfactory evacuations. After the 
bowels have been free :1 if there is little or no return of the pain 

and much less tenderness in the right inguinal region, the patient should 
be simply kept at rest under the influence of a mild anodyne for two or 
three days, and convalescence will be established. So long, however, as 
there remains much pain, tenderness ;: s v-ding. more decided anodynes 
internally and emolient applications externally, should be continued. 

In addition to the foregoing, in all the more severe cases of peritypl i] 
I have seen much benefit result from the prompt application of leeches 
directly. over the seat of the inflammation. In adults irom six to twelve 
leeches may be applied, and allowed to take all the blood they will, 
and when they fall off. the g from the bites may be continued by 

the application of warm cloths and emolient poultices, as I have previ- 
ously indicated. Of course in children and young subjects, the number 
of leeches will have to be diminished in proportion to the the child. 

In a decided majority of instances. I should say at least three out oi four 
of all the cases that have come under my observation during the last 
thirty years, the treatment I have now indicated has been followed by the 
ultimate recovery of the patients. But in those cases where the treat- 
ment has been neglected or inefficient during the early stage until it has 
become evident that suppuration has been established, the earlier an in- 
cision can be made wit: safety so as to give exit to the matter, the more 
certain will be the recovery of the patient. If you wait until the abscess has 
become so large as to bring the matter near the s making a distinct 

pointing. Ft fluctuation, it will be at the immine t risk of some of 

those bad terminations, that I have already pointed out. namely, ulcera- 
tion into the intestines, into the peritoneum, or into the bladder, causing 
the patient, sometimes, seedy death, and at others, a lingering sickness 
and death after many months of suffering. So important is it to open 
these abscesses early, that some of our most eminent authorities have rec- 
ommended making incisions in an explorative manner as early as there 
are any just reasons to suppose the suppurative pro-^ss had commenced, 



BILIOUS COLIC. 547 

and without waiting for any evidences of fluctuation, or the ability to de- 
tect matter by the ordinary process of palpation. Drs. Willard Parker, 
Guerdon Buck and some others, many years since, demonstrated the 
feasibility in these cases, of making an incision just above and paral- 
lel with Poupart's ligament, through the abdominal parietes, as deeply as 
the fascia covering the muscular structure, and then proceeding 
in the subsequent steps, to very carefully sever one layer after another 
as in the cutting over a hernial sac for the relief of strangulated hernia, 
until they had reached a proper depth for penetrating the abscess, if any 
existed; or when having made an incision down close to the vicinity, in- 
serting an exploring needle still deeper, for the purpose of determining 
whether an abscess existed or not, and the precise point of its location. 
Several cases are recorded where this operative procedure has been fol- 
lowed by the desired relief in the discharge of pus, and the very early 
restoration of the patient. 



LECTURE LIV. 



Inflammation of the Intestines Continued— Bilious Colic, its Pathology and Treatment— Colitis 
and Recto-Colitis or Dysentery; its Causes, Symptoms, Morbid Anatomy, Diagnosis, Prognosis and 
Treatment. 

GEXTLEMEX: Before leaving the subject of inflammation and irrita- 
tion affecting the small intestines, I will direct your attention very 
briefly to a class of cases that you are liable to meet with at any time in 
practice, occurring more frequently in persons from five to twenty vears 
of age than at an earlier or later period of life; though they may occur at 
any period from infancy, even to old age. I refer to cases that, in former 
times were called bilious colic. The patient is usually attacked rather 
suddenly with a pain in some portion of the abdomen, accompanied by a 
sense of heat and slight tenderness. The pain is usually of an acute 
character and distinctly paroxysmal. There is at first little or no fever 
or general disturbance of the temperature, pulse or respiration, but simply 
a severe paroxysmal pain accompanied by a continuous sense of heat, and 
slight tenderness at a particular limited portion of the abdomen, more 
generally near one or the other of the iliac regions; sometimes directly in 
the umbilical region or central part of the abdomen. In three cases out 
of four, however, it is in the region of the right iliac fossa, and ascending 
colon. But whatever may be the particular seat of the pain, after it has once 
commenced, there is generally an entire suspension of further evacuations 
from the bowels. Although I have been in the habit of inquiring very 
closely, I have rarely found one in which the bowels had been consti- 
pated during any preceding part of the time before the attack, but they 
had either moved at regular intervals daily, or as in some instances had 
been loose. Very recently a case occurred in which the patient had two 
or three unusually free evacuations from the bowels only a few hours 
before the attack. Yet, from the beginning of the pain, there was as 
usual an entire arrest of further evacuations. If these cases are not in- 
terfered with, their natural tendency is to induce in a few hours more or 
less nausea or rejection of the contents of the stomach by vomiting, after 



548 BILIOUS COLIC. 

which the stomach continues to reject whatever is taken in the way of in- 
gesta, including drinks, nourishment, and very frequently medicine, ac- 
companied by a steady increase of the tenderness, with some tumefaction 
at the place of pain. This swelling is seldom circumscribed, as in peri- 
typhlitis, but is more diffused and not accompanied by any well-defined 
local hardness. The urine becomes scanty and high-colored, sometimes 
creating a burning sensation while passing, the pulse steadily 'increases 
in frequency and diminishes in force, the patient becomes more and more 
restless until the end of the second or during the third day. If no 
relief is obtained he is then liable to have cold extremities, a pinch oti 
and anxious expression of countenance, great sense of prostration and 
weakness, sighing in his breathing, like one tired; pulse small and thready; 
the whole abdomen distended, tympanitic, and more or less tender to 
pressure; a continuation of the paroxysms of vomiting, the matters ejected 
being the contents of the stomach, mixed with more or less 
mucus, either of a grass-green or dark-brown color. A little later 
it presents the full, coffee-ground appearance, and is thrown up in large 
quantities by regurgitation, entire prostration ensues, relaxation of 
the sphincters, and death. There is, of course, much variation in 
the severity of attacks of this character. Some of them are much 
milder than I have described, and even without any other treatment than 
rest and abstinence from food and drinks, and perhaps the use of such 
domestic remedies as warm cloths, applied over the abdomen, freely, the 
pain before the end of twenty-four hours subsides spontaneously, evacua- 
tions from the bowels occur, and the patient speedily recovers. But 
there are all gradations in severity, from these simple slight cases up to the 
severe and dangerous grade that I have already described. 

The nature of these cases is often misunderstood. So far as my observa- 
tions go, a large majority, both of the people and of the practitioners who 
are called to their aid, receive and act upon the impression that the colic or 
pains are produced by some irritating substance in the alimentary canal, 
and that the great desideratum in the treatment is, to cause its removal 
by obtaining free evacuations from the bowels. And I think I do not err 
in saying that in four out of five of all the cases to which J have been 
called in consultation, in the last twenty years, the treatment has been 
commenced by giving remedies to procure evacuations. It is true that 
in many of them, anodynes have been administered to allay pain, but at 
the same time the anodynes have been alternated with doses of physic, 
the one to allay pain, the other apparently to force an operation from the 
bowels; and the result has been, without exception, that the administra- 
tion of the physic so far counteracted the effects of the anodyne, that the 
pains were continued to a gre ter or less degree, and within twenty-four 
hours the irritability of the stomach was developed to such an extent as 
to reject by vomiting everything further that was administered by the 
mouth. In some instances, seeing the inadvisability of further adminis- 
tering either physic or anodynes by the mouth on account of their rejec- 
tion, hypodermic injections of morphine have been resorted to, and in 
some instances, with the effect of speedily relieving the pains and 
putting the patient at rest. And had the rest been allowed to remain a 
sufficient length of time, there is a probability that it would have resulted 
in permanent relief to the patient, especially if aided at suitable times 
by large enemas, instead of disturbing the stomach. In the majority of 
instances, however, still controlled by the idea that some irritative material 
must be removed by evacuations, the patient has only been allowed to 
rest for three or four hours under the influence of anodynes, when active 



SYMPTOMS. 549 

closes of physic were again administered only to be promptly rejected, 
with a renewal of more distress and persistent vomiting than before, fol- 
lowed by greater prostration of the patient, and an increase of all the 
abdominal symptoms. I saw a marked illustration of this only a few 
weeks since, in the case of a youth who had been attacked in the manner 
I have already indicated. He had three evacuations in the morning 
before the attack commenced. The pain coming suddenly and with great 
severity, a physician was called without delay who judiciously admin- 
istered anodynes at first, sufficient to allay the pain; but with the idea 
that I have already indicated, he deemed it of paramount importance to 
freely evacuate the alimentary canal, and consequently commenced giv- 
ing mild laxatives and alteratives alternated with his anodynes. 

The result was a failure to do more than mitigate the pain, and to de- 
velop active vomiting before the e nd of twelve hours. He then ceased to 
administer medicine by the mouth and resorted to hypodermic injections 
of morphine, and succeeded in quieting the patient, procuring considerable 
rest, and so much apparent improvement that there was supposed to be 
no longer any danger in the case. But as the effects of the anodyne more 
completely passed away, the pains began to return and with the pains 
again came the idea that it was necessary to remove the contents of the 
bowels, consequently two old-fashioned doses of calomel and jalap, ten 
grains each, were administered for this purpose. They were followed by 
prompt vomiting, with a rapid increase of the pain, tympanitis and tender- 
ness over the whole abdominal region, with excessive distension, great 
prostration of the patient, and yet no evacuations that were supposed to 
pass through the alimentary canal. This led to the conviction on the part 
of the attending physician that there was probably invagination of the 
intestine, or intussusception. So strong was this conviction that prep- 
arations were made for an effort to obtain relief by causing gaseous 
distension of the bowels, through the use of enemas, and in case of failure, 
perhaps, to resort to laparotomy for the purpose of unfolding the supposed 
invagination. These ulterior measures, however, were not resorted to, 
and the patient became so rapidly prostrated as to die on the third day 
after the time of the administration of the calomel and jalap. And yet on 
careful post-mortem examination, no invagination of the intestines was 
found, and no positive mechanical obstruction. At two points there were 
contractions of the circular fibers of the muscular coat, of the intestine, suf- 
ficient, perhaps, to diminish the caliber of the intestine at those points 
more than one half. They appeared to be the only mechanical impedi- 
ments to the movement of the bowels. Death was plainly the result of 
intense inflammation, commencing in the muscular and peritoneal cover- 
ings of the intestines and extending over the whole peritoneal surface. I 
regard this class of cases as dependent on primary irritation causing 
irregular contraction of the circular fibers of the muscular coat of a limited 
part of the intestine by which the natural peristaltic motion is arrested, 
and the severe pains induced. Such irritation may result from reflex 
nervous action or from the direct presence of undigested material in the 
bowels. Some of these cases I have traced directly to the presence of 
indigestible material, or other substances that had been swallowed by the 
patient. In one of the earliest cases that came under my care, the attack 
appeared to be provoked by a long walk after eating an abundance of 
pop-corn, some of which was swallow 7 ed without chewing. It was in the 
person of a woman, who had been confined less than two weeks previously, 
but had gotten up from her confinement well. Having taken the corn as 
I have mentioned, she walked about a mile and a half carrying her baby, 



550 BILIOUS COLIC. 

and before the next morning, was seized with all the symptoms I have 
described as characterizing the more severe cases of the class under con- 
sideration. In this case the symptoms proceeded to an extreme degree; 
the abdomen became enormously distended from tympanitis. There was 
tenderness over its whole surface, pulse small, thready, vomiting constant, 
the matters ejected being first green and later of a brownish hue; ex- 
tremities cold, and altogether presenting an aspect that had caused her 
physician to regard the case as hopeless, and the friends were collected 
to see her die. No evacuations had taken place from the time of the 
attack of pains, except such faeces as were then in the lower part of the 
bowels. Being requested to see the patient at this stage of her difficulty, 
and learning minutely the history of the case, I advised, as a forlorn hope, 
the administration of an enema consisting of an infusion of tobacco, under 
the impression that the disease was, what I have already indicated, namely, 
direct contraction of the circular fibers of a limited portion of the intestine 
without invagination; and consequently if that contraction could be re- 
laxed, evacuations would occur. Knowing of no more powerful relaxant 
of general muscular tone or of tonic contraction than tobacco, when its 
full sedative effects are obtained, I advised its administration in the form 
of an enema. The amount given was sufficient to cause very decided 
effects upon the nervous and muscular systems of the patient. 

Within twenty minutes she became pale, the surface covered with a 
sweat, and a feeling as though she was dying. The pulse was very soft 
and weak and the mind wandering, but this state was followed in the next 
twenty minutes by a copious evacuation from the bowels, filling the bed 
with fasces, before the patient could give any warning, and in less than 
an hour, two additional evacuations followed; greatly lessening the ab- 
dominal distension, and under the influence of a little carbonate of am- 
monia and camphor as restoratives, the stomach became quiet, the pulse 
improved, and the patient went on to subsequent recovery without the 
necessity of any other treatment than simple anodynes to restrain the ex- 
cess of the evacuations during the day following the administration of the 
tobacco enema. This case to which I have alluded occurred more than 
thirty years since; and from that time to the present I have regarded these 
attacks as consisting essentially in a grade of irritation, involving the 
muscular coat of the intestine primarily and inducing an arrest of peri- 
staltic motion or a contraction of the circular fibers at one or more parts 
and the development of inflammation only as a secondary consequence. The 
case which I have just detailed showed in the evacuations an abundance 
of the identical corn in kernels apparently as whole as when they were 
swallowed a week previously. But there are many of these cases in 
which no traces of any foreign substance can be found in the evacuations 
to explain why they occurred. And some of the patients manifest a pe- 
culiar susceptibility to such attacks, having them recur once or twice a 
year for several years in succession. Entertaining the views I have just 
explained, in relation to their pathology, I have uniformly adopted the 
practice of giving such remedies only, at first, as were calculated to pro- 
duce full relaxation of the muscular fibers and to relieve the pain; and to 
continue this influence long enough to render it reasonably certain that 
the irritability of the structures involved had been fully overcome; care- 
fully abstaining from the administration of cathartics of any kind dur- 
ing the first two or three days of the treatment. When the pain and irri- 
tability have been fairly checked by the prompt use of anodynes, I have 
found the administration, first, of large injections of warm water not only 
to be useful in provoking evacuations, but apparently exerting more or 



TREATMENT. 551 

less soothing influence as indicated by the sense of relief following their 
use. 

After giving two or three enemas of warm water sufficient to invite 
evacuations, if they fail to produce that effect, and the pains, with more or 
less abdominal distension, begin to return, then I think there are no reme- 
dies more certain to induce the necessary relaxation, and relief from pain, 
than injections either of the hydrate of chloral and belladonna, or of the 
infusion of tobacco, as I have already indicated when speaking of other 
forms of intestinal obstruction. The latter I have had used many times 
in cases, where, previous to being called in consultation, the attending 
physician has been led to conclude with much positiveness, that an invag- 
ination of the intestines had taken place, and yet with speedy and entire 
relief to the patient. Consequently, I urge upon you in treating all these 
cases to divest yourselves of the idea that j^ou must procure by cathartics, 
earlv evacuations from the bowels, whether you have reason to suppose the 
patient has taken some indigestible material or not. And, for the simple 
reason that if there is indigestible material or some foreign substance in 
the alimentary canal, it having already induced circular contraction of the 
intestines, and arrested the peristaltic motion, all efforts to excite further 
cathartic action will only cause still closer contraction, and speedily in- 
duce inversion of intestinal motion, vomiting, and consequently much 
additional distress and danger to your patient. On the contrary, if you 
first administer such remedies as will allay pain, dull the morbid sensi- 
bility of the part, and induce ultimate relaxation of the walls of the con- 
tracted portion of the intestine, then an efficient use of enemas or even 
of mild laxatives will succeed in procuring all the evacuations that are 
necessary, and with entire safety to the patient. 

On the contrary, nothing is more clear than that if a tube like the in- 
testine is contracted at one point by a band of circular fibers, while above 
and below, it remains uncontracted, or of the usual size, the more you 
provoke movements that are. calculated to force a passage downward, the 
more certain you will be to carry the contracted portion into the uncon- 
tracted part below, and thereby produce an invagination, which would 
not have taken place, if your efforts had been directed to the prevention 
of such motion until the unnatural contraction had ceased. Consequently, 
whether we view the matter theoretically, or as demonstratedl by experi- 
ence, the rational mode of treatment is first to so far destroy the morbid 
sensibility and irreg-ular contraction as to remove the resistance to the 
passage of the contents of the bowels before you insist on efforts to pro- 
cure such passages. I have thus dwelt upon this class of cases because 
they are of comparatively frequent occurrence, and because I am 
satisfied that both the pathological relations I have pointed out, and 
the indications for treatment, are of much practical value. 

Recto-colitis or Dysentery. — Inflammation of the mucous membrane of 
the large intestine and rectum are met with, of all grades of severity, 
from the most acute and rapidly progressive to the most chronic or pro- 
tracted in duration. Inflammation of the membrane lining this part of 
the alimentary canal very generally extends more or less to the muscular 
coat. And while it often occupies the whole extent of the colon and rec- 
tum, it is more frequently limited to certain portions, or at least is more 
intensely developed in certain parts, as the caecum, the right and left 
angles of the colon, and the sigmoid flexure, than in the transverse por- 
tion. It prevails more or less every season, and is then called spo- 
radic, or simply acute dysentery. At some periods of time, and in some 
localities, it prevails to such an extent, as to present all the characteristics 



552 DYSENTERY. 

of an epidemic; and occasionally extends from place to place over an ex- 
tended district of country in the same manner as other true epidemic 
diseases. More frequently, however, when it prevails severely, it is 
limited to particular communities, and is more properly styled endemic, 
than epidemic. At the present time, writers are inclined to describe two 
forms of the disease; one, styled simple or catarrhal dysentery, and the 
other croupous or pseudo-membranous dysentery, sometimes also called 
diphtheric dysentery. This division, however, is one that can not be 
maintained clinically at the bed-side; for observation has abundantly 
shown, that cases of the pseudo- membranous, or diphtheritic form of 
dysentery, occur frequently interspersed among other cases of a strictlv 
catarrhal character. On the other hand, cases of simple or catarrhal 
dysentery occur very frequently intermingled with those of a diphtheritic 
character, especially when the disease is prevailing with more than 
ordinary severity. 

All forms of dysentery, whether sporadic or endemic, prevail most in 
warm climates, especially within what are called tropical countries, where 
the summer temperature is long continued; and also more frequently in 
warm seasons of the year in temperate climates. Indeed, throughout the 
temperate zone of the earth, dysentery rarefy prevails, except during the 
last months of summer, and the first of autumn. In the northern belt of 
the United States, its prevalence is limited almost entirely to the months 
of July, August, September, and sometimes extending through a portion 
of October. Its highest average prevalence is usually in the month of 
August. The order in which the intestinal diseases appear in our coun- 
try, is, usually, first, the serous diarrhoeas, cholera morbus, and cholera 
infantum, connected with and immediately following the climax of sum- 
mer heat. As we pass this climax, we begin to have the prevalence of 
dysentery, and a little later, the autumnal fevers make their appearance, 
showing that there is a relationship in the order of the prevalence of these 
diseases. 

These facts in regard to the climates and seasons most favorable for the 
prevalence of dysentery, show that there are certain predisposing causes 
that exert a strong influence over the production of the disease; such as 
the extreme high temperature of the warm climates or tropical regions; 
the warm days and cool nights of the last months of summer and early 
autumn in the temperate regions. To these, which are evidently strong 
predisposing causes, may be added, also, certain other changes, such as 
the existence of over-crowding, want of ventilation, as illustrated in the 
denser populated portions of cities, especially among the inhabitants of 
tenement houses and manufacturing establishments, where many workmen 
are congregated in small dwellings, also still more in work-houses and 
prisons, where sanitary regulations have been overlooked, and in the 
camps of armies. 

Dysentery, in the endemic or epidemic form, appears to be of fre- 
quent occurrence in connection with the movements of large armies, 
in almost all the countries of the tropical and temperate regions of the 
earth. Few diseases were more destructive to life and health than dys- 
entery in connection with our army during some portions of the war for 
independence, again with the army that invaded Mexico, and still more 
in the armies on both sides in the recent civil war. Another influence 
which seems to predispose to the prevalence of dysentery is malaria, or 
the active cause of periodical fevers; it having been observed in 
almost all cases, that dysentery was more prevalent in those decidedly 
malarious districts than in non-malarious ones, under otherwise similar 



HISTORY. 553 

conditions of temperature and of season. And it has also been noticed that 
the seasons of the highest prevalence of malaria itself were usually charac- 
terized by an increased prevalence of dysentery. This fact, however, has 
been noted by many observers, that while malarious fevers were prevalent 
upon the low lands in malarious districts, dysentery was often observed 
to be decidedly more prevalent on the neighboring or adjacent elevations 
and ranges of hills. It would seem that age also exerted some influence 
as a predisposing cause, from the fact that much the larger proportion of 
the cases of dysentery are met with in adult life. It is true that cases 
occur at all periods of life, even from infancy to old age; but a far larger 
proportion of them are met with between the ages of fifteen and forty, 
than at an earlier or later period. And, while dysentery undoubtedly 
prevails most as an endemic disease, recurring with different degrees of 
severity in different years in malarious districts, and in densely populated 
towns and cities where the population is subject more or less to the causes 
which favor the development of typhoid and typhus fevers, it is by no 
means restricted to those localities. Occasionally it has prevailed, and 
that, too, in its most malignant form, in hilly, rugged districts of country, 
which were almost entirely free from malarious influences, and among a 
rural population as much as among those occupying towns and villages. A 
few such instances have come under my own observation. I recollect well 
when the disease prevailed with great severity, destroying many lives 
through a wide district of the middle and southern portions of New 
York; embracing the larger parts of the counties of Otsego, Chenango, 
Courtland, Broome, Tioga and Steuben in a single season during the 
latter part of summer and autumn; it assumed as malignant a character 
in the isolated farm houses of well-to-do farmers directly upon the rugged 
hills, as in any other portion of the district. 

In the reports from the various committees upon epidemics, and some 
of those on pract ; cal medicine to be found in different volumes of the 
w Transactions of the American Medical Association," especially during 
the first fifteen or twenty years of the history of that organization, are 
allusions to, and descriptions of many epidemics of dysentery. For prac- 
tical and clinical purposes I may include the various cases of acute dysen- 
tery in three groups: one, that I shall designate as acute sthenic, or active 
dysentery; another malarious, or periodical; and a third as asthenic, or 
typhoid. Not that these are different forms of disease in any respect, 
but simply that the first includes those cases generally of a sporadic 
character though sometimes epidemic, which occur in otherwise healthy 
districts of country, and in populations not debilitated or constitutionally 
influenced by any other general causes. While the second group in- 
cludes those cases, which are met with oftentimes endemically in dis- 
tinctively malarious districts of country; and the third group embraces 
such cases of dysentery whether sporadic or endemic, as occur in the 
midst of sanitary influences well known to predispose to typhoid con- 
ditions of the system. These groups are not different diseases, but 
simply the same disease; essentially an acute inflammation in a particular 
portion of the alimentary canal; but occurring under different modify- 
ing circumstances: — such as have altered more or less the condition of 
the blood, the secretions, and the vital properties of the tissues. 

Symptoms. — The symptoms of acute, active or sthenic dysentery are 
usually well marked and easily recognized, as diagnostic of this disease. 
Some cases commence abruptly with a chill, but in the great majority of 
cases, the patient feels, from one to three days, a gradually increasing 
disturbance in the abdomen; consisting of rumbling of gases, increased 



554 ACUTE DYSENTERY. 

peristaltic motion of the bowels, occasionally slight griping pains, and 
from one to three or four intestinal discharges per day. During this 
premonitory stage the discharges are foetid but thinner than natural. 

In most instances, at the end of from one to three days of the premonitory 
disturbances to which I have alluded, the discharges become more frequent, 
smaller in quantity, and consisting largely of mucus, together with a dis- 
position to strain, called tenesmus, while each discharge is usually pre- 
ceded and accompanied by much more severe pains across the abdomen, 
sometimes called tormina. In addition to these frequent paroxysms pass- 
ing through the abdomen, and the tenesmus and pressure upon the rectum, 
accompanying the frequent smali mucous discharges, there is usually also a 
dull moderately severe pain in the sacral region of the back, not infre- 
quently some frontal headache, with a great sense of weariness; there is 
dryness of the mouth, often some thirst, a whitish coat upon the tongue, a 
slightly reddened appearance of the lips, moderate acceleration of the pulse, 
and an increase of from one to three degrees of temperature above the 
normal standard, with a dryer feeling of the skin, and often a slightly 
flushed appearance of the face. In other words, with the supervention of 
frequent, painful, scanty mucous discharges, there comes a moderate 
general febrile action. The urine, also, becomes at this time diminished 
in quantity, redder than natural, and not infrequently giving rise to 
some burning and irritation in the urethra when discharged. Usually, 
within twenty-four hours after the discharges become small and mucous, 
they become, also, more or less streaked and intermixed with blood, and 
after the first two or three days the general febriie movement increases 
moderately in severity, the tongue and lips become more dry, thirst more 
decided, the pulse is increased in frequency, until it often reaches ninety- 
five to a hundred beats per minute, the temperature in some instances 
reaches from 30° to 40° C. (102° to 104° F.), the pains preceding and accom- 
panying the discharges become extremely sharp and severe, while there is 
almost constant feeling of fullness in the rectum. The patient suffers from 
distressing tenesmus, often no sooner rising from the vessel and returning 
to bed than he is again compelled to be up with a vain effort to pass more, 
when perhaps with all his efforts, the matters passed will be no more than 
a spoonful of simple jelly-like mucus, intermixed with blood. In the 
severer class of cases the stomach often becomes irritable, drinks which 
the patient craves very frequently are rejected by vomiting, and in a 
small proportion of the cases the vomiting becomes so frequent and 
urgent as to seriously interfere with the administration of both medi- 
cines and nourishment. 

In a large majority of cases, however, the stomach remains quiet, and 
usually the mind free from disturbance or delirium. In cases of ordinary 
average severity, in about three days the discharges begin to change. 
The mucus presents more of a whitish or opaque appearance, and 
the blood is more intimately intermixed with it. The quantity 
passed each time, also, is larger, while the passages are a little less- fre- 
quent. With this change in the appearance of the discharges to a more 
muco-purulent character, the skin becomes less hot, the mouth a little 
less dry, and if there has been a coat upon the tongue it begins to disap- 
pear, especially along the edges, and the patient gets longer intervals of 
rest, between the paroxysms of pain or griping, either with or without 
the intestinal discharges. In those cases tending toward a favorable re- 
sult, the changes I have just mentioned become more and more promi- 
nent, until about the fifth or sixth day, when the discharges will begin to 
lose their mucous, or muco-purulent character, and to present more of 



SYMPTOMS. 555 

an intermixture ot ordinary faeces. The urinary secretion which had pre- 
viously been very scanty, and often passed with pain, now becomes freer 
than usual, and is passed with ease. The temperature, also, will be found 
to have returned nearly to the natural standard and the mouth to have be 
come quite free from dryness. The tenesmus and straining at stool now 
rapidly diminish and the discharges from this time on grow less and less 
frequent, until by the end of the week from their beginning, or at the 
longest, the middle of the second week, there will be no longer any- 
thing of a dysenteric character. 

Those cases of dysentery, of moderate or average severity, will thus 
be found to run their course to convalescence, in from seven to nine days; 
and they will often do this with no medication whatever. This was 
proven by the clinical observations of Dr. A. Flint, Sr., in 1875, who re- 
ported the management of ten cases of acute dysentery of ordinary, 
average severity, that were allowed to run their course, wholly independ- 
ent of any medication; under, of course, good regulation of the diet, 
thinks, and everything of a sanitary character. These ten cases were 
found to reach a spontaneous termination in convalescence in different 
periods of time; but the average time of the whole number was from eight 
to nine days. While it is true that the milder cases of dysentery, whether of 
sporadic or endemic prevalence, are thus inclined to terminate, within 
from seven to ten days on an average, spontaneously, it is equally 
true that the severer class of cases, perhaps occurring at the same seasons, 
intermingled in the same communities, if left to themselves, will run a 
much more dangerous course, and yield a large ratio of deaths. 
When cases of this class are left to their own course, they begin 
with the same symptoms I have described in all respects, except perhaps 
developing more suddenly with less prodromic stage, and when developed, 
exhibiting more urgency in the frequency of the discharge, and a greater 
degree of tenesmus and more severe griping pains. The pulse at the be- 
ginning is more accelerated often ranging from a hundred to a hundred 
and twenty per minute, the temperature, sometimes even in bad cases, 
remaining low or only a little above the normal standard, but in others 
rising on the second or third day to 40° or 40.5° G. (104° or 105° F.) with 
the skin dry, and a continuation of nausea, depression, dryness of the 
mouth and lips. The patient feels a great sense of prostration, with 
much distress at the epigastrium, and generally a troublesome inclination to 
vomit. These more severe cases present the same succession of changes 
in the evacuations as I have already described. 

But after the first three days, the quantity of muco-purulent material 
becomes increased, presenting more of a yellowish color, and the blood in- 
termingled with it is of a darker hue; the urine at the same time becoming 
very scanty, is often almost as painful in its passage as are the dysenteric 
discharges. The patient suffers all the symptoms of extreme prostration, 
not infrequently the extremities become cold and bluish, the mind is wan- 
dering, the pulse soft, small, almost thready at the wrist, and the respirations 
are irregular and sometimes sighing. Such cases, if not modified by treat- 
ment, are very liable between the fifth and the seventh days to present 
evacuations of a very thin dark brown or reddish brown color, emitting 
an offensive or putrid odor, in which if closely examined, may be found 
shreds and patches of the mucous membrane, sometimes from one to two 
inches in length. These discharges are not so frequent as at first, but 
much larger in quantity, and soon become involuntary, or at least par- 
tially so. Occasionally it will happen, at this stage, when the discharges 
have become almost involuntary, and the patient greatly prostrated, that 



556 ACUTE DYSENTERY. 

a larger intermixture of blood will appear; or a true hemorrhage; followed 
very speedily by complete collapse and death. The most acute and rap- 
idly progressing cases, often of the sthenic variety of the disease, are 
those reaching a fatal termination between the filth and seventh days; 
but the great majority of cases that terminate fatally, do not do so 
until the middle or latter part of the second week, and in some instan- 
ces, not until the end of the third week. If they continue beyond this, it 
is usually in the chronic form, on account of the extensive ulcerations left 
from the disintegration and sloughing of the mucous membrane; and al- 
though they may terminate ultimately, in death, yet where of the chronic 
form, the duration may be many weeks. 

The symptoms of the periodical, or malarious form of dysentery, differ 
from the group of cases I have just described, chiefly in two particulars; 
namely: in the mode of beginning, and periodicity. Almost all of this 
class of cases, after a period of perhaps one or two days of moderate loose- 
ness of the bowels or slight diarrbcea, begin the active dysenteric symp- 
toms abruptly by a chill, usually of brief duration, but sufficient to be 
easily recognized. The chill is immediately followed by a general fever, 
usually of an active type, and directly associated with all the local 
phenomena of severe dysentery; such as severe pains in the loins and 
sacral region, sharp cutting pains through the abdomen, frequent desire to 
evacuate the bowels, the character of the evacuations being similar to 
what I have previously described, and the temperature almost always 
higher than in the other class of cases. Indeed, the dysenteric phenom- 
ena, and the general fever in this class of cases, usually present a very 
active and severe gr tde, leading the practitioner, if he first comes to the 
case in the paroxysm, to suppose the patient has a very severe and danger- 
ous attack. But this intense activity in the sj^mptoms usually continues 
from five to twelve hours, when it begins to decline; and, in a short time 
all the active phenomena have ceased, the temperature falls nearly to the 
natural standard, and in many instances a slight moisture appearing upon 
the surface, the patient falls into a quiet sleep. 

This remission in the symptoms continues until the same period of 
time in the twenty-four hours at which the first chill occurred, when the 
symptoms of dysentery and fever both reappear, — usually, however, with- 
out a marked chill, but the dysenteric symptoms and the general fever both 
present as much severity as in the first paroxysms, and continue longer 
before the next remission. We thus have a true periodical or exacerbat- 
ing type of dysentery. If appropriate treatment is neglected, each return- 
ing paroxysm reduces the patient's strength, and usually is more protracted 
than the previous one, until at the end of five or six days, the remissions 
are much less distinct than at first, and the dysenteric discharges are con- 
tinued but not with an equal degree of activity through the whole twenty- 
four hours. In a majority of the cases the coating upon the tongue becomes 
dry, and more brown, the abdomen tender to pressure, the pulse soft, com- 
pressible and frequent. The urine is scanty. The mind of the patient often 
wanders during the height of the exacerbation, but is clearer during the rest 
of the time. The discharges change as in any other case of dysentery from 
a jelly-like mucus, streaked with blood, to a muco-purulent character, and 
if not terminated by the end of the first week, almost always become more 
copious but less frequent, and when reddish brown contain, on ciose ex- 
amination, shreds such as were previously mentioned, indicating disintegra- 
tion and sloughing of portions of the mucous membrane, and not infrequent- 
ly, are pretty copiously intermixed with dark blood, and yield a decidedly of- 
fensive or putrid odor. When such cases are allowed to continue two w 7 eeks, 



SYMPTOMS. 557 

or more, they end in entire prostration, involuntary discharges, collapse 
and death. In this class of cases, there appears to occur more or less 
congestion of the liver, and of the spleen, indicated by an increased area of 
dullness on percussion over the hypochondriac regions, and sometimes 
by the projection of the edges of the organs below the margins of the 
ribs. In hot climates inflammation of the interior of the liver is very apt 
to occur, terminating in suppuration and a hepatic abscess ; sometimes 
there will be only a single abscess, but more frequently a number of them 
in the hepatic structure. It is comparatively rare that a hepatic abscess 
forms in connection with dysentery in the temperate climates, yet cases 
do occasionally occur in this and all other countries. Not less than four or 
five cases have come under my observation. Three of these, however, 
took place after the dysenteric disease had assumed a chronic form. 
The symptoms of the third form of dysentery, or that which I have de- 
nominated asthenic or typhoid, differ from both of the others, more partic- 
ularly in the character of the discharges, and in the grade of continued 
fever. It is seldom that the symptoms are ushered in by a chill, but 
most frequently commence with thin diarrhceal discharges, not more 
than two or three for the first day, but increasing the second, and becom- 
ing more decidedly of a dysenteric character, that is, consisting mostly of 
a bloody serum, instead of mucus, streaked with blood. In these cases 
the discharges will usually vary in quantity from sixty cubic centimeters 
to two hundred and sixty (fl. ^ii to |viii>). The discharges are accom- 
panied by less acute and distressing pains across the abdomen, consid- 
erable tenesmus, although not as acute and severe as in the more active 
or sthenic grade of the disease. From the beginning the patient has a 
dull, heavy expression of countenance, often suffused with dark redness, 
the temperature is then seldom more than 37.7° to 39° C. (100° to 
102° F.); the pulse is soft, easily compressed, in some cases much accel- 
erated in frequency, and in others preternaturally slow, with occasional 
intermittence. 

The patients of this class are much less restless and uneasy than those 
suffering from the acute form of dysentery. The discharges are seldom as 
frequent, but being larger in quantity, and an intermixture of serum and 
blood, the latter usually of a dark color, they undergo loss of strength 
more rapidly than in either of the other forms of the disease. In the most 
severe cases of this class, such as I met with often during the cholera 
epidemics from 1849 to 1854, and again in I860, the discharges of bloody 
serum were sufficiently copious and frequent to prostrate the patient al- 
most as rapidly as the regular attacks of epidemic cholera. Alter the 
first twenty-four hours the discharges were not only considerable in quan- 
tity, and largely intermixed with blood of a dark hue, but there were many 
specks or flakes of a whitish color floating in the bloody serum, giving to 
the whole mass much the appearance, in some instances, of the w T ater in 
which bloody pieces of lean meat had been washed. Some of these cases, 
if not promptly influenced by judicious treatment, failed so rapidly as to 
cause entire prostration, involuntary intestinal discharges, suppression of 
urine, cold extremities, dull, drowsy condition of mind, and finally entire 
collapse and death at the end of the third, or during the fourth day. The 
larger number of fatal cases, however, terminated between the fifth and 
seventh days. This is a much more fatal form of dysentery than either 
of the o x her varieties. Still it varies greatly in its severity in different 
seasons and in different localities, much depending upon the previous tone 
and health of the individuals attacked, and still more upon the sanitary 
surroundings in which they are placed. The first time I met this form 



558 DY^EXTERY. 

of dysentery was in 1849, during the severe epidemic of cholera 
that prevailed in this country in the summer of that year. I was 
then a resident of New York city. The cases began to occur about the 
time the epidemic of cholera reached its climax; became more frequent 
as the epidemic declined, and the attacks of dysentery continued to re- 
cur for some three or four weeks after those of cholera had ceased. 

Moving from New Y'ork to Chicago in the latter part of that season, I 
mot with moderate epidemics of cholera, in the latter city, during the 
summers of 1850, '51, '52, and a very severe epidemic in '54. Again, a 
moderate epidemic prevailed in this city as well as in other parts of the 
country in 1866. In all these seasons, I saw cases of this typhoid or as- 
thenic type of dysentery, more strongly marked than I have seen at any 
other periods of time. Yet but few seasons have passed during the whole 
of my residence in this city that I have not met with some cases of 
dysentery that presented the characteristics of this particular grade. In 
most of the seasons they have been limited to patients who were occupy- 
ing badly ventilated rooms, or exposed to atmospheres contaminated by 
accumulations of animal and vegetable matters undergoing decomposi- 
tion, as in unclean alleys, in rear houses, or in places in which they were 
using water more or less contaminated with organic matter derived from 
percolation through the surface soil. In connection with armies, dysen- 
tery is not infrequently found to prevail under circumstances in which 
another element is exerting an influence: namely, scorbutus or scurvy. 
During the civil war in this country, there were some instances in which 
portions of the army were subject to a decidedly scorbutic influence, at 
the same time they were occupying a malarious region and also sur- 
rounded by more or less of the causes that produce typhoid fever. It may 
be said that the causes of typhoid fever, malarious fever, and scorbutus 
were acting coincidently. Under such circumstances, the occurrence of 
dysentery proved to be one of the most intractable forms of acute disease 
that the members of the medical staff had to encounter. Of all those 
who were invalided and sent to the North for more favorable conditions 
of recovery, none were found more difficult of management and restora- 
tion to health, than the cases of chronic dysentery that had originated 
under the combination of influences I have just mentioned. All the 
forms of dysentery I have described are liable either to terminate spon- 
taneously in recovery in from one to three weeks, or to proceed to a 
fatal termination within the same limits of time, or to become moderated 
in severity, and continue in a chronic form for an indefinite period. 
Cases of dysentery are met with among children particularly, every 
summer, which follow attacks of cholera morbus and serous diarrhoea. 
Although secondary to the choleraic attack, yet after having assumed the 
characteristics of dysentery, their tendency and general progress are 
similar to those I have already described. 

Anatomical Changes. — The appearance of the mucous membrane af- 
fected with dysenteric inflammation varies much in different cases, more 
particularly on account of the differences in the intensity of the inflam- 
matory process. In all cases in the first stage, the membrane is intensely 
injected with blood, giving it various shades of redness, from a bright 
red color to a dark brown, and when it has proceeded to a fatal termina- 
tion, usually causing decided softening and impairment of the texture* 
In those cases which have been denominated simple or catarrhal inflam- 
mation, the parts of the membrane affected most are the folds and parts 
containing the glandular structures. In addition to the various shades 
of deep redness, the membrane is tumefied or swollen, altered in various 



ANATOMICAL CHANGES. 559 

decrees in its texture, perhaps always, in acute cases, in the direction of 
softening; the submucous tissue much infiltrated with liquor sanguinis, 
containing plenty of leucocytes or white corpuscles, and in some instances 
small points of red corpuscles, or slight extravasations of blood. In 
some instances these changes also exist in the muscular coat, but in a less 
degree. The mucous membrane itself contains numerous lymphoid cells, 
pus corpuscles and fibrinous exudate, not only filling the interstitial 
spaces of the membrane, but obstructing the tubules and follicles in some 
places to such an extent as to cause necrosis and sloughing of the super- 
ficial layers of the structure; thus giving to the more intensely inflamed 
portions of the membrane the appearance of irregular and more or less 
extensive ulcerations. In the grade of inflammation which has been 
called diphtheritic, the disease invades the tissue more deeply, and in- 
stead of being limited largely to the prominent folds of the mucous mem- 
brane, it permeates as extensively the base of these folds or the whole 
membrane continuously, and causes a greater degree of tumefaction on 
account of the more copious infiltration into the submucous tissue, and 
in some instances into the muscular coat, and leads to a larger amount of 
fibrinous exudation into the interstitial spaces, both of the submucous 
tissue and of the mucous membrane proper. Under the microscope, you 
have the appearance of lymphoid cells, or white corpuscles and pus glob- 
ules interspersed with more or less of fibrillated fibrin. These substances 
fill up more or less closely the interstitial spaces, and in some places crowd 
upon the tubules, and block the vessels so much as to cause more exten- 
sive necrosis and sloughing of the mucous membrane than in the catar- 
rhal cases, and leave deep, irregular ulcerations on a large part of the sur- 
face. 

Not infrequently in those portions of the membrane where the changes 
of structure have been greatest, the inflammatory process extends through 
to the peritoneal coat, causing its outer surface to be injected with blood, 
sometimes covered with fibrinous exudation, by which adhesions are formed 
between coils of the intestine. Cases have occurred in which the ulcers 
have extended through the peritoneum, permitting more or less of the 
contents of the intestine to escape, and yet the coincident fibrinous ad- 
hesions prevent the diffusion of the matter into the general cavity of the 
peritoneum and lead to a circumscribed abscess. In other instances the ad- 
hesions not limiting the diffusion of the faecal matter, general peritonitis, 
speedy collapse, and death has followed. While in nearly all cases of 
acute and subacute inflammation of the colon and rectum whether of the 
catarrhal, croupous or diptheritic grade, the membrane undergoes soften- 
ing disintegration, or sloughing and ulceration to a greater or less degree, 
in the chronic form of the disease, the submucous tissue becomes infil- 
trated with more plastic material and the mucous membrane itself be- 
comes more or less indurated and thickened, while its appearance is ren- 
dered very unequal and ragged with ulcerations varying from the most 
superficial to those penetrating deeply into the tissues. Some cases of 
the acute form of dysentery have occurred, in which in limited portions 
of the intestines more especially in the sigmoid flexure and upper portion 
of the rectum, deep and extensive ulcers have formed from the sloughing 
of the tissues, and yet convalescence has followed, and these deep and 
large ulcers have ultimately been repaired by granulation and cicatriza- 
tion. But the cicatrices, and cicatricial tissue here, as in most other struct- 
ures of the body contract after the cicatrices have been completed; and 
in doing so, they have caused permanent alterations in the caliber of the 
intestine, by projecting like bands across portions of its diameter, and 



500 DYSENTERY. 

somotimos to ?o great an extent as to constitute strictures that seriously 
obstruct the passages of the bowels. Such cases, although the patients 
recover for a time, are extremely liable to be followed, sooner or later, 
by the setting up of chronic inflammation above these strictured portions, 
where the faeces are kept lodged an undue length of time, and always to 
give much annoyance in the procurement of regular evacuations. I have 
a patient now under observation, seriously annoyed by a stricture dimin- 
ishing the caliber of the intestine more than one half, situated just at 
the lower portion of the sigmoid flexure, which resulted from a severe 
attack of acute dysentery some fifteen years since. The only wav by 
which she can be rendered comfortable is to secure just that degree of 
relaxation of the bowels, by which the faeces are rendered semi-fluid. 

Diagnosis. — The symptoms which I have described as characterizing 
the different stages in the progress of acute and subacute dysentery are 
so characteristic in their nature as to render the diagnosis of the disease 
comparatively easy. From inflammation of the membrane lining the small 
intestines, it is distinguished by the greater amount of pain, especially 
tenesmus, and the more decidedly mucous discharges, almost always more 
or less intermixed with blood. The only two other conditions which 
might possibly be mistaken for dysentery, are habitual constipation in 
which the sigmoid flexure and portion of the rectum have been allowed 
to become filled with hardened fasces, causing local irritation in the 
rectum. These cases are to be differentiated from true dysentery, first 
by carefully inquiring as to the preceding condition of the patient; which 
would develop the fact that the bowels had been not only habitually 
costive, but probably that there had been no faecal evacuations for sev- 
eral days before the irritation in the rectum was manifest; and secondly, 
by direct examination of the rectum, which would disclose the fact that 
it was filled with impacted, or hardened faeces. The other morbid con- 
dition which may simulate in some respects dysenteric symptoms is the 
presence of inflamed hemorrhoids, or piles. Dilatation and sacculation of 
the hemorrhoidal veins constituting one form of hemorrhoids, not infre- 
quently are accompanied by sufficient inflammatory action, more espe- 
cially when some of the more dilated vessels get strangulated by being re- 
tained in the sphincter, after a passage of the bowels, to give rise to much 
of the same kind of feeling or desire to frequently evacuate the bowels, 
with sense of fullness or pressure in the rectum as exists in dysentery. 
But such cases are seldom accompanied by any discharge of mucus, 
neither will there usually be any general febrile symptoms or disturbance 
of the appetite and secretions. But a more immediate means of differ- 
entiating this class of cases will be in the direct examination of the rec- 
tum, thereby ascertaining the existence of the hemorrhoidal tumors. 

Prognosis. — The prognosis, in acute and subacute dysentery, will vary 
much from the great differences in the severity of the disease in different 
seasons, and especially in the different periods of its epidemic prevalence. 
A very large proportion of all the cases of sporadic dysentery have a 
tendency to recovery, and consequently the prognosis is generally fa- 
vorable. In much the larger proportion of cases, in those seasons when it 
may be said to have an endemic or even an epidemic prevalence, the in- 
flammation causes so much destruction of the mucous membrane as to 
prevent recovery. Such cases will usually reach a fatal termination in 
from one to two weeks. There are some seasons in which dysentery pre- 
vails in so malignant a form, that more than one half of all the cases 
terminate fatally; but such epidemics are rare. Within my own experi- 
ence I have met with no season of its prevalence in which the mortality 



TREATMENT. 561 

exceeded one in ten or twelve of the whole number coming under obser- 
vation. And, with the exception of two or three seasons of unusually 
severe prevalence, the mortality has not reached one in twenty-five or 
thirty cases. Such as have terminated fatally have usually been of the 
class I have denominated typhoid, occurring among those who are sub- 
jected to unfavorable sanitary influences, and who generally neglect to 
secure proper medical attendance until the disease has made considerable 
advancement. 

Treatment. — Much diversity of opinion seems to exist, even at the 
present day, among writers of eminence, in regard to the best mode of 
treatment in acute and subacute attacks of dysentery. Many claim that 
the treatment should be almost invariably commenced by the administra- 
tion of saline cathartics, sufficient to cause free evacuations from the bow- 
els; others recommend oleaginous cathartics, as castor oil. The advantages 
claimed for the administration of either saline or oleaginous laxatives, 
especially the first in the commencement of dysenteric inflammation, are, 
first, to remove supposed retained fasces, or other irritating matters in the 
alimentary canal, and second, to deplete the congested vessels by the in- 
creased effusion caused by the operation of the saline class of cathartics. 
Even those writers who readily assent to the fact that nineteen-twentieths 
of all the cases of dysentery begin with diarrhoea, and thereby show con- 
clusively that the alimentary canal contains no hard fasces, or accumula- 
tions of any kind other than the ordinary secretions, nevertheless assent 
to the general direction to commence treatment by a saline laxative, for 
the purpose of making sure that the contents of the bowels have been 
properly evacuated. , 

Another, perhaps smaller class of writers, advocate with the most de- 
cided confidence the commencement of treatment by the administration 
of large doses of ipecac; claiming that the administration of from one to 
three grams (gr. xv to xlv) of ipecac in a single dose in the early stage 
of the disease, and the same repeated twice in the twenty-four hours, will 
produce the most decided amelioration in the condition of the patient, 
and modify favorably the subsequent progress of the disease. It is con- 
ceded, that in most cases, the first dose will produce free, often copious 
vomiting; but it is claimed that the subsequent doses will be retained, 
and from one to three such doses retained will be sufficient to cause free 
fascal evacuations from the bowels, apparently containing a liberal quan- 
tity of the coloring matter of bile, with little or no pain at the time of the 
evacuation. These bilious stools are sufficiently characteristic to receive 
the designation of ipecac stools ; and in some instances they have ap- 
peared to be followed by a rapid subsidence of all the phenomena of in- 
flammation, and an early recovery of the patient. In hot climates where 
dysentery is more severe and more liable to proceed to an early fatal 
termination, and at its outset involves a higher grade of inflammatory 
action, there are not wanting those who regard a free venesection at the 
commencement of the disease, as of much value in moderating its further 
progress. My own experience in regard to the use of large doses of ipecac 
has not been uniformly favorable. On the contrary, in a majority of the 
cases in which I have exhibited it, the p itients have not only been vom- 
ited freely by the first dose but equally so by the second and even by the 
third. And, in two or three instances, the stomach remained so irritable, 
as to reject subsequently almost everything, in the way of either medicine, 
drink, or nourishment, and apparently was the cause of an early and un- 
due degree of prostration. In some other cases, after the first dose, the 
medicine was retained, and in from twelve to eighteen hours, free char- 
36 



r 



62 DYSENTERY. 



acteristic evacuations from the bowels followed, with much relief to the 
sensations of the patient, but the relief was not permanent. In from six 
to twelve hours the intestinal discharges began again to recur, and grad- 
ually assumed more and more of the characteristic mucous and bloody 
appearance; and in twenty-tour hours more, all the symptoms of the dys- 
enteric disease were re-established, almost as actively as before the ad- 
ministration of the remedy. On the other hand, in a lew cases, the ipecac 
treatment has been followed by the most satisfactory results. In one 
case of a very acute and severe character, in which twenty-four hours had 
passed before I saw the patient, the symptoms indicated a case of the utmost 
gravity. I directed thirteen decigrams (gr. xx) of ipecac to be mixed with a 
little syrup and taken at once, and the same to be repeated in six hours. 
At my next visit I found that both doses had been retained, no vomiting 
had occurred, and the tenesmus and frequent desire for evacuation had 
almost entirely ceased. I then ordered smaller doses to be continued 
every four hours, and during the next twelve hours three or four copious 
yellowish brown faecal evacuations occurred, after which there was no re- 
turn of the dysenteric discharges, and the patient reached a very early 
convalescence. Another was a case of dysentery following confinement, 
sometimes called puerperal dysentery. In this instance the stomach was 
excessively ir/itable, and would neither retain ipecac nor any other med- 
icine. On account of this extreme irritability of the stomach, I caused 
ipecac, combined with a few drops of the tincture of opium to be admin- 
istered per rectum. Three grams (gr. xlv) of ipecac, and two cubic 
centimeters (min. xxx) of the tincture of opium in one hundred cubic 
centimeters (fl. |iii) of milk-warm water, were administered as an enema, 
the parts being supported for a few minutes after the withdrawal of the 
syringe, and the whole was retained, producing entire relief from suffering 
and causing the patient in one hour to fall into a comfortable sleep. In 
about three hours, what was left of this enema passed off, and was soon fol- 
lowed by moderate tenesmus, and some cutting pains across the abdomen. 
Another enema of the same material was immediately used. This was 
followed by the same entire relief, which was of longer duration than after 
the first. After this no symptoms of returning dysenteric irritation oc- 
curred for twelve hours. Then another enema, containing only half the 
quantity of ipecac and tincture of opium was administered. I have no 
doubt but there are cases, if we could discriminate them properly, in 
which the administration of ipecac in the beginning of the disease — and 
the earlier it is dene the better — would be followed by a speedy and 
entire arrest of all the symptoms. But my own experience has led me 
to believe that a large majority of the cases, as we meet with them in 
ordinary general practice, can not be treated as successfully in this way 
as by other means. The distressing vomiting that often follows the first 
administration of the ipecac, is not compensated for by any degree of 
permanency in the relief obtained; and unless the temporary relief is 
followed up by other medicines calculated to secure a continuance of the 
result, in nearly all the cases the effects of the remedy will be temporary 
in their duration. 

And my observation has shown, that the same remedies, which are nec- 
essary to secure and perpetuate the beneficial results of the ipecac, will 
in most cases quite as efficiently secure all those results, if administered 
without the ipecac. In regard to the administration of cathartics of any 
kind, saline or otherwise as the initial step in the treatment of acute dys- 
entery, I have become satisfied by a very long and abundant experience, 



TREATMENT. 563 

that the rule gi?en by most writers is altogether too broad: and leads to 
the use of evaouant remedies not only when unnecessary but often when 
decidedly injurious to the patients. It must be remembered, that a lame 
majority of the cases commence with diarrhoea, and that there is no evi- 
dence whatever of the retention in the bowels of a single ball of hardened 
faeces, nor any other morbid material, except the products of the inflam- 
mation itself. Simply removing these products, without modifying the in- 
flammation, is merely a work of supererogation, as the patient's own efforts 
at stool, every ten, twenty, or thirty minutes, evacuate them quite as fast 
as they are formed. My rule has been, when called to a case of dysen- 
tery, uniformly to make a careful inquiry as to the character and extent 
of the fecal evacuations at the commencement, and for one or two days 
prior to the beginning of the disease. Whenever it appears from such 
inquiry that there may be retained faeces, either in the middle of the in- 
testinal canal or in any part of the colon, and especially if on making 
careful examination by palpation over the abdomen there is. any indica- 
tion of fullness, that is not gaseous but faecal in any part of the 
course of the colon, I do not hesitate to commence treatment with 
a sufficient amount of saline laxatives to cause one, two, and sometimes 
three free evacuations from the bowels. But as I have intimated, these 
inquiries result in at least forty-nine cases out of every fifty, in furnish- 
ing full and satisfactory evidence, that there are no retained, or accumu- 
lated faeces in any part of the alimentary canal. Consequently in all such 
cases I proceed directly to the administration of such remedies as will 
most certainly allay pain and diminish the extreme morbid excitability of 
the inflamed structures, until the intestines are put entirely at rest. I 
usually combine the anodyne, which is required for this purpose, with 
such alteratives as will be likely to moderately excite the various natural 
secretions of the system; more especially those of the kidneys, skin, 
and other important glandular structures. If it be within the first 
twenty-four hours after the commencement of the attack, and the skin is 
dry, the temperature somewhat elevated, the desire for evacuations fre- 
quent, the urine scanty, I have generally prescribed a powder composed 
of pulverized opium one decigram (gr. iss) nitrate of potassium three 
decigrams (gr. v) and mild chloride of mercury six centigrams 
(gr. i), to be taken every two hours until the pains and tenesmus are 
relieved, and the patient inclined to sleep. 

In those instances which are occasionally met with, in which the gen- 
eral febrile acti' n is more active, giving a temperature of 39° or 40° C. 
(103° or 104.5° F.), with a coating upon the tongue, and much thirst, I 
have given between these powders a mixture of nitrous ether and cam- 
phorated tincture of opium each forty- five cubic centimeters, (fl. §iss) and 
tincture of veratrum viride four cubic centimeters (fl. 3i), in doses of four 
cubic centimeters (fl. 3i) diluted with a little water. Under these influ- 
ences the patient usually begins to feel some degree of relief within the 
first six or eight hours, which is gradually increased with each renewed 
administration of the medicines, until before the end of the first twenty- 
four hours,, there will be an entire suspension of all the more severe symp- 
toms, some moisture upon the skin, and the patient will be inclined to 
sleep. When this is the case I leave out the mild chloride of mercury 
from the powders, and extend the interval between the tim3 of their ad- 
ministration to four hours instead of two, and continue the liquid prescrip- 
tion as before, between the doses of the powders, and in this way allow 
an interval of twelve or eighteen hours to elapse. If during that time 
the bowels have remained quiet, without further discharges, I suspend the 



564 DYSENTERY. 

use of the powders altogether, and give an enema of warm water to be 
administered in sufficient quantity to fill up the rectum well, for the 
purpose of provoking moderate evacuations from the bowels. In the great 
majority of instances this will be followed within half an hour by an evac- 
uation, that is semi-fluid, faecal, and usually tinged a yellow or greenish 
color, such as is popularly called a bilious stool. In almost all instances 
this will be followed in one or two hours by another evacuation of a sim- 
ilar character. This will be accompanied by a sense of relief to the pa- 
tient, and if the administration of medicine is now allowed to remain sus- 
pended, in most instances another discharge will follow in less than an 
hour, containing a little mucus, and accompanied by slight griping pains 
across the bowels. If not interfered with the passages will continue 
to increase in frequency, and by the end of twenty-four hours from the 
time of procuring the first stools the patient will be suffering from a return 
of all the dysenteric symptoms, but a little less severe than at first. 

This result, however, can be prevented usually, and should be, by care- 
fully providing the patient with some anodyne medicine to.be taken 
immediately after the second evacuation from the bowels. One of the 
best medicines for this purpose is a combination of the aromatic sulphuric 
acid, sulphate of magnesia, and tincture of opium mixed with water in the 
proportion of four cubic centimeters (fl. 3i) of each of these ingredients 
to thirty cubic centimeters (fl. |i) of water; of which four cubic centi- 
meters (fl. 3i) should be administered, diluted with sweetened water, 
immediately after the second faecal evacuation of the bowels. The same 
may be repeated after every evacuation until the bowels have again be- 
come entirely quiet. In a great majority of instances, two or three doses 
will so far control further evacuations, that the patient will be very com- 
fortable, and the discharges will not occur often er than once in from three to 
four hours. And in three or four days they will have assumed an entirely 
healthy faecal character, and there will not be more than one or two in the 
day; in other words, the patient will have reached the commencement of 
convalescence. It is seldom that the veratrum viride, which was placed 
with the nitrous ether and camphorated tincture of opium in the liquid 
prescription is needed more than the first forty-eight hours. While in a 
large majority of the cases of ordinary sporadic dysentery, the remedies 
which I have thus far indicated, when they are used as recommended, 
will be sufficient to guide the patient to an early convalescence, you will 
meet with many cases, especially in seasons when the disease is prevailing 
in the more severe or endemic form, in which the inflammatory action 
will be more persistent. In such cases the discharges soon assume a more 
distinctly muco-purulent character, mixed with blood, and accompanied 
by some tenesmus and the continuance of a low grade of febrile action. 

Under such circumstances I have found no remedy equal in value to 
the emulsion, containing oil of turpentine, oil of wintergreen and tincture 
of opium rubbed together thoroughly with gum arable, sug-ar and water, 
the formula for which I have given you when speaking of the treatment 
of the advanced stage of typhoid fever, and more recently in the same 
condition of inflammation in the mucous membrane of the ileum (see p. 53:)) 
Four cubic centimeters (fl. 3i) of this emulsion given every two, three or 
four hours to an adult according to the frequency of the evacuations, will, 
in a large majority of even the more severe cases, produce a very speedy 
and decidedly beneficial effect by steadily lessening the frequency of the 
discharges, diminishing the amount of blood in them, and generally 
causing their entire arrest in from three to four days. The doses should 
be given frequently at first, and the interval lengthened in proportion as 



TREATMENT. 565 

the discharges diminish, thereby limiting the latter to one or two in the 
twenty-four hours, until they become natural in quality, rather than en- 
tirely suppressed. If the discharge of urine is painful, as is often the case 
in this disease, it may be much lessened by giving between each of the 
doses of the emulsion four cubic centimeters (fl. 3i) of an equal mixture 
of the liquor ammonii acetatis and nitrous ether. If the pulse is decid- 
ed! v weak, fifteen minims of the tincture of digitalis may be added to 
each dose of the liquor ammonii acetatis mixture with much benefit. In 
children and sometimes in adults, I have found that the emulsion con- 
taining turpentine proved more or less offensive to the stomach, and after 
taking a few doses was rejected by vomiting. In other instances when 
it has not been rejected, after its continuance at frequent intervals for 
three or four days, it has added to the irritation of the neck of the blad- 
der, and induced symptoms of strangury. When either of these circum- 
stances occur it should be discontinued, and in its place I give a gelatine 
capsule containing' carbolic acid, pulverized ipecac and pulverized opium, 
in such proportions that each capsule will contain sixteen milligrams 
(gr. J) of the carbolic acid, twelve centigrams (gr. ii) of the ipecac, 
and six centigrams (gr. i) of the opium. A pill or capsule containing 
these ingredients may be given to an adult every two, three or four hours 
until the dischargos are arrested, and then given at intervals sufficient to 
hold them in check until the inflammatory action has subsided, and the 
discharges returned to a more natural character. In children, the ordi- 
nary carbolic acid mixture may be given (see formula p. 138) in doses, 
to a child five years of age for instance, of tw T enty or thirty minims every 
three or four hours, and instead of having any tendency to nauseate the 
stomach, it allays nausea when it already exists, and seL om fails to im- 
prove the discharges, both in their frequency and their quality. If, under 
the influence of these or any other remedies which may be administered, 
the dysenteric disease manifests a tendency to continue and assume a 
chronic form, one of the best remedies that can be found is the nitrate 
of silver in combination with pulverized opium and extract of hyoscya- 
mus in the form of a pill; in the proportion of two centigrams (gr. %) 
of the nitrate of silver, and six centigrams (gr. i) each, of the extract 
of hyoscyamus and pulverized opium, in each pill. As the activity of 
the symptoms has already abated, and the disease assumed a more chronic 
form, it will be sufficient to give one of these pills once in from four to 
six hours. 

If, when given at these intervals, they do not exert the necessary 
restraining influence over the frequency of the discharges, they maybe 
aided by giving moderately full doses of the turpentine and laudanum 
emulsion previously alluded to, each night and morning. You will 
notice that I have omitted from the list of remedies recommended for 
the management of acute and subacute dysentery all the more active 
class of ordinary astringents, such as gallic acid, representing the 
various vegetable astringents, and acetate of lead, sulphate of alumin- 
ium, etc., representing the mineral astringents. I have done this pur- 
posely, because my own clinical experience has satisfied me that they 
can seldom be used in these forms of the disease without checking 
other secretions, at the same time that they temporarily lessen the exu- 
dations from the mucous membrane of the colon and rectum; and con- 
sequently that their effects as a whole are not beneficial to the patient. 
In giving the clinical history of dysentery, I mentioned a class of cases 
liable to occur in malarious districts, that are modified in their progress 
by the coincident action of malaria upon the system, especially at seasons 



5ti6 D TSENTERY. 

of the year when that agent is mainly exerting an influence upon the 
community. The only decided difference, however, in the management cf 
that class of cases, from the ordinary active form of dysentery, consists in 
the early and efficient administration of quinine, or some other reliable 
antiperiodic, in addition to the ordinary remedies addressed to the local 
inflammatory disease. The best antiperiodic for this purpose is undoubt- 
edly the sulphate of quinine, and the most favorable time for its admin- 
istration is at that part of the twenty-four hours corresponding with the 
remission in the febrile paroxysms. And during such remission it is de- 
sirable to administer the quinine in such doses, that from twelve to 
twenty grains shall be given during each of the first two or three days. 
Subsequently it is seldom necessary to give more than from six to eight 
grains in the twenty-four hours until convalescence is established. By 
simply supplementing the ordinary treatment, as I have given in detail, 
with the use of quinine, or any efficient substitute of an antiperiodic nature, 
you will be able to control nearly all the cases of dysentery in malarious 
districts that come under supervision at an early period of their progress. 

A third variety of dysentery, or distinct class of cases, was described as 
occurring under circumstances and sanitary influences such as favor the 
development of typhoid conditions of the system and giving to the dys- 
entery a distinctly asthenic grade of action, from the beginning. In 
these cases, as I have already stated, the discharges are more of a bloody 
serum in the early stage, than a jelly-like mucus. The pulse is softer, 
weaker from the beginning, and the whole aspect of the patient is that of 
a depressed and typhoid condition. Some of these cases tend very rap- 
idly to extreme exhaustion and early collapse. Consequently they require 
to be met promptly with appropriate remedies. This is particularly the 
case during the seasons when the disease assumes an epidemic character. 

When called to this class of patients, if I find the discharges quite 
large in quantity, decidedly serous, tinged with dark blood and recurring 
as often as every half hour, with a soft compressible pulse, dingy and 
depressed appearance of the countenance I usually commence treat- 
ment by giving a powder consisting of acetate of lead thirteen centi- 
grams (gr. ii), pulverized opium six centigrams (gr. i.) and calo- 
mel three centigrams (gr. ij-), every four hours, and four cubic centi- 
meters of the same solution of aromatic sulphuric acid, sulphate of mag- 
nesia, and tincture of opium that I have previously mentioned, half way 
between the powders; causing them to alternate two hours apart — -some- 
times only an hour and a half apart. At the same time I direct an ene- 
ma to be given immediately after every evacuation from the bowels, 
containing six decigrams (gr. x) of acetate of lead and three centi- 
grams (gr. +) acetate of morphia, dissolved in two ounces of cold 
water. I mean literally that I give this enema immediately after each 
evacuation from the bowels. 

If the patient is allowed to wait ten or fifteen minutes after an evacua- 
tion, before the enema is administered, time enough will have 
elapsed to have caused more or less accumulation of the bloody serum 
in the rectum, together with the ability of the muscular coat of the intes- 
tine again to take on peristaltic or expulsive action, and the enema, if 
then given will be promptly forced back. But if the materials are ready, 
and the enema is administered as soon as the patient has finished his evac- 
uation, and returned to a recumbent position, and as the pipe of the 
syringe is withdrawn, the anus is supported for a few minutes, by pressing 
the nates together or supporting it with a napkin, it will very frequently 
be retained long enough to exert a very important influence, in aiding to 



TREATMENT. 567 

suppress this class of discharges. I have known some very severe cases 
of this disease to be controlled, by the combined influence of medi- 
cines given by the mouth and rectum, so promptly that the patients 
were placed at the end of the first twenty-four hours in a comparatively safe 
condition. If these means succeed in actually arresting the discharges, it is 
desirable that the doses be simply given at longer intervals, so as to main- 
tain the effect until the bowels have remained quiet for at least twenty- 
four hours. If no evacuations occur during that period of time, all reme- 
dies containing anodynes may be suspended, and the patient allowed to 
take small quantities of properly prepared wheat flour and milk gruel at 
intervals of half an hour or an hour, with perhaps a tablespoonful of 
strong tea or coffee, either with or after the doses of the gruel, until 
eio-hteen hours more have passed, during which in a very large proportion 
of the cases, evacuations will have returned. Not as at first, however, 
but more of a semi-fluid, or faecal character,. though sometimes a little 
tinged with blood; and the first one or two unaccompanied by pain. If 
such evacuations occur spontaneously, immediately after the second move- 
ment of the bowels, the solution of aromatic sulphuric acid, sulphate of 
magnesia and tincture of opium should be resumed, and the doses should 
be repeated now after every evacuation; or if no further evacuations 
occur, once in about four hours, for two or three days. If the urinary 
secretion has been scanty, it will be profitable to give the patient between 
the doses of the last named medicine, either a teaspoonful of the nitrous 
ether diluted with water, or an equal quantity of the nitrous ether and 
liquor ammonii acetatis. If the pulse be quite weak and soft, it will be 
proper to add from ten to fifteen minims of the tincture of digitalis, to 
each of the doses of the diuretic. I have seen many of the cases, of what 
are termed typhoid dysentery, as promptly arrested by this method of 
treatment as the ordinary cases are, by the treatment recommended for 
them. 

But when cases are not brought under treatment until the disease has 
progressed one or two days, or if the remedies as used, fail to control the 
progress of the discharges, and the patient becomes more decidedly ex- 
hausted, as indicated by a very soft, weak pulse, cold and leaden hue of 
the extremities, sunken eyes, torpid or wandering condition of the mind, 
partial loss of control over the sphincters, so that the bed is frequently 
soiled before the patient can give warning of the desire to evacuate the 
bowels, I have found no remedy or combination of remedies, that has 
been equally valuable with that of strychnia, nitric acid, and tincture of 
opium; a convenient formula consisting of strychnia, six centigrams 
(gr. i), nitric acid, four cubic centimeters (fl. 3i), tincture of opium fifteen 
cubic centimeters (fl. 3iv) simple syrup and water a hundred and twenty 
cubic centimeters (|iv). Of this, four cubic centimeters (fl. 3i) diluted 
with additional water, may be given at first every two hours. And at 
the same time injections may be given either of the acetate of lead 
and morphia, as previously recommended, or gallic acid and tincture of 
opium, and repeated under the same regulations as mentioned before. 
In addition to the medicines, these cases should also be sustained by giv- 
ing at least twice between each of the doses of the strychnia solution one 
or two tablespoonfuls of the flour and milk gruel, with equal quantities of 
the tea or coffee, or their active principles, caffeine or theine. Where it 
can be had, the caffeine is perhaps preferable to either an infusion of 
coffee or tea. But an ordinary strong cup of coffee with a little milk and 
sugar will usually answer a good purpose by being taken with the gruel, 
thus furnishing small quantities of nourishment in the most convenient 



508 CHRONIC DYSENTERY. 

condition for absorption, while the tea or coffee shall act as a true nerve 
excitant. You thereby counteract the tendency to stupor and drow- 
siness, and thus maintain or assist in maintaining the general functions 
of nutrition and innervation. The strychnia also is given with a view 
of exerting a prompt and strong influence in sustaining the sensibility 
and action of the nervous centers; for it is through failure of these, and 
the consequent failure of the capillary circulation, accompanied by gen- 
eral suppression of secretions, with relaxation of the sphincters, that the 
patient is hastened directly into collapse and death. I have derived the 
most satisfactory results from the use of the combination of strychnia, 
mineral acids and opium, in the treatment of this class of cases; and have 
seen many recoveries from conditions that w r ere supposed to be hopeless.- 

Of course as the discharges become less frequent and copious, and less 
bloody under the influence of the enemas and the strychnia and opiate so- 
lutions combined, the frequency of the doses of the latter should be dimin- 
ished, but only in proportion as the discharges become less frequent, aiming 
always to limit them to one or two in the twenty-four hours until they 
become natural. I have seen nothing but disastrous results from the use 
of cathartics in this class of cases of dysentery. In a few instances I 
have derived very decided advantage from the use, in the first stage, of 
pretty full doses of ipecac and morphine in the form of enema; 
thirteen decigrams (gr. xx) of the ipecac and three centigrams (gr. ^) 
morphine in sixty cubic centimeters (|ii) of water, may be passed into the 
rectum immediately after each evacuation until the latter ceases to recur. 
If from any cause, cases of an asthenic or typhoid type of dysentery are 
only partially controlled during the active stage of the disease, and 
manifest a tendency to assume the chronic form after the general fever 
has subsided, and the discharges continue at the rate of from three to six 
in the twenty-four hours, being less of the bloody serous character, but 
containing more evidence of a muco-purulent material, they will generally 
be found to diminish steadily until convalescence is established, by giving 
them the ordinary turpentine and laudanum emulsion, alternated with 
the strychnia and nitric acid solution; each prescription may be given 
once in six hours, making them alternate three hours apart. Particular 
attention throughout all stages of this variety of dysentery should be given 
to the support of the patient by judicious nourishment. 

Chronic Dysentery. — When inflammation of the mucous membrane of 
the colon and rectum has assumed a decided chronic form, whether as 
the sequel of an acute attack, or as a primary disease, there is usually no 
general febrile action, or increased heat, little or no tendency to coating 
upon the tongue, or much dryness in the mouth, and but little interfer- 
ence with secretions, either from the skin or kidneys. But the patient 
is troubled with paroxysms of griping and commotion in the bowels, fol- 
lowed by tenesmus of a moderate character, and either muco-purulent or 
sero-purulent discharges, varying in frequency from two to six or more in 
the twenty-four hours; not infrequently the patient being able to be up 
and dressed, and sometimes going out almost every day. The evacua- 
tions in such cases are almost always more numerous and urgent, on the 
patient's first rising from the bed in the morning, or the tendency is mani- 
fested for one or two evacuations, soon after taking food at each meal- 
time. Sometimes the amount evacuated each time is considerable, con- 
sisting of thin reddish brown, slightly faecal material, more or less offen- 
sive in its odor, and at other times persistently maintaining the character 
of small muco-purulent discharges, streaked here and there with blood. 
Examination under the microscope will, in almost all these cases, detect 



ANATOMICAL CHANGES. 569 

an abundance of pus, detached epithelium, not infrequently shreds of 
necrosed or detached portions of the mucous membrane. The patient 
pretty steadily emaciates and loses strength, until after many months, 
and sometimes two or three years of suffering, he reaches the stage of 
fatal exhaustion. The final failure is preceded in many instances by 
more or less oedema of the extremities, apthous ulcerations of the mouth 
and fauces, scanty, and sometimes albuminous urine, and occasionally, 
though rarely in our climate, the supervention of suppurative inflammation 
in the liver, giving rise to hepatic abscesses. The anatomical changes 
which are found in cases of chronic dysentery, may be found copiously 
and admirably illustrated in one of the volumes giving the medical his- 
tory of the late civil war. Indeed, I would refer you to these volumes, in 
which there is a large amount of very valuable matter pertaining espe- 
cially to the anatomical changes, and the great variety of results that are 
liable to occur in the progress, not only of the different grades of dysen- 
tery, but of all the inflammatory affections of the alimentary canal, partic- 
ularly as they are modified by camp life in connection with armies, and 
an exposure both of the causes of periodical fevers on the one hand, and 
of typhoid fevers and scorbutus upon the other. 

The most important anatomical changes are the thickening and indura- 
tion of the folds of the mucous membrane in whatever part of the colon or 
rectum the disease has existed; these folds being in many cases so thick- 
ened from the infiltration and induration of the sub-mucous connective 
tissue as to give them the appearance of ridges, and sometimes of 
polypoid projections into the caliber of the intestine. 

The epithelial layer of the membrane, over much of the inflamed 
surface, is either removed or much disturbed. In some places the whole 
depth of the mucous membrane is destroyed by necrosis or sloughing, 
leaving ulcerations of considerable extent, with irregular edges, and 
separated often one from another by thin, narrow strips of tumefied, or 
dark red tissue, causing the intestine when laid open, either in the rec- 
tum, sigmoid flexure, or at the angles above, to appear like a dark red and 
extremely ragged or irregular surface, resting upon a thickened and 
hardened sub-mucous tissue as a base. Now and then a case will be 
met with in which these ulcerations have penetrated so deeply into the 
tissue that their base rests upon the peritoneal covering, and even occa- 
sionally penetrates this membrane, inducing the ordinary consequences of 
intestinal perforations, namely: general acute peritonitis and death. 

Prognosis. — The prognosis in purely chronic dysentery should always 
be given with caution; for though there are many of the milder class of 
cases, in which the anatomical changes to which T have alluded are of 
limited extent, and patients under judicious treatment, both in regard to 
hygienic measures and medicine, will recover, yet in other cases w 7 here 
these changes are very extensive, occupying a large part of the surface 
of the colon, they will be found entirely incurable. All remedies, how- 
ever varied and judiciously applied, prove only palliative in their effects, 
and the disease proceeds until the patients are ultimately reduced to a 
fatal degree of exhaustion. In their management, the regulation of the 
diet and drinks is a matter of very great importance. The principle 
should be here ps in all cases of dysentery and diarrhoea, to have the 
patient use such articles of nourishment, and in such forms as are capable 
of being most perfectly absorbed and converted into nutritive material 
and taken up by the vessels of the stomach and first part of the aliment- 
ary canal, leaving the smallest possible amount of faecal residue to pass 
over the diseased surfaces, whether in the ileum, colon or rectum. As I 



570 CHRONIC DYSENTERY. 

have had occasion several times to remark, the material which answers 
this purpose perhaps better than any other, and at the same time pos- 
sesses all the ingredients necessary for supplying the human system is 
milk, either alone or mixed with a small proportion of lime-water, or still 
better, with a small proportion of wheat flour, in the form of a thin 
homogeneous flour and milk gruel. While this constitutes the best basis 
for nutrition that has been devised, to prevent the patient from becoming 
disgusted with its constant use, it may be alternated with more or less of 
the various animal broths, such as beef tea, chicken broth, mutton broth, 
all of which, when used, should be seasoned with salt to suit the patient's 
taste. Sometimes it will be well to give the patient the albumen of egfr, 
separated from the yolk, and simply intermixed or suspended in water, 
administered in small quantities. 

The patient should avoid taking all such vegetables as consist mostly 
of starch, like potatoes, very tender bits of meat" being much more likely 
to be digested and well borne than potatoes, beets, or even most varieties 
of bread. As a rule it is better that the patient take nourishment in very 
limited quantities, and at such stated intervals as will give a reasonable 
amount of support in every twenty-four hours, experience having fully- 
shown that when the secretion of gastric juice is lessened by wasting 
disease, if any form of nourishment is taken in considerable quantities, a 
portion of it is very liable to undergo fermentation, and create more or 
less disturbance, before the whole of it can be taken up by the absorbents. 
Whereas, if the same material is taken in smaller quantities and at such 
intervals as will allow what is taken atone time to have been fully absorbed 
before the next quantity is taken, the patient will avoid the retention 
of any long enough to undergo fermentation, and yet he gets the amount 
necessary in the twenty-four hours. In regard to the remedial agents to 
be used in the treatment of chronic forms of dysentery, I can give you 
no better direction than to use the same formulae that I have already 
given for the treatment of the advanced stages of the acute form of the 
disease, simply adjusting the doses, and the time of their administration, 
in such a way that they shall so far control the di&charges as to keep 
them as near one in the twenty-four hours as may be possible, until the 
injured portions of the inflamed membrane can undergo the process of 
reparation and cicatrization. The patient should persistently use some 
combination which possesses the qualities of a soothing or anodyne agent, 
with that which will increase the tone or contractility of the vessels of the 
inflamed part, thereby constantly repressing the excess of blood in the 
tissue, and lessening also the morbid susceptibility, until a renewal of 
nutrition, granulation and cicatrization is induced in the ulcerated parts. 
At the same time the capillary vessels and circulatory organs will be 
aided in removing from the thickened and indurated structures any 
adventitious material that may have been added to them by either 
exudation, cell proliferation or any other mode of thickening and hyper- 
trophy of the connective tissue. In my own experience, though trying a 
large variety of remedies as they have been suggested from time to time, 
I have found none to succeed better in the treatment of the different 
grades of chronic dysentery, than either the turpentine, oil of winter- 
green, and laudanum emulsion; carbolic acid, ipecac and opium pills or 
capsules; or nitrate of silver, hyoscyainus and opium in the form of pills, 
all of which I have already mentioned in speaking of the treatment of 
the more acute form of the disease. It is impossible to give a rule by 
which you can judge, in any given case which of these formulae will be 
productive of the greater amount of good. Observation has fully satis- 



TREATMENT. 571 

fied me that direct clinical trial is the only test. I have found a con- 
siderable majority of the cases of chronic dysentery to be benefited in a 
greater degree and for a longer period of time by taking four cubic centi- 
meters (fi. 3i) of the turpentine and laudanum emulsion from three to 
four times in the twenty-four hours, than from either of the other com- 
binations alone. Next to this I have placed the combination of carbolic 
acid, ipecac and opium; and as the third in rank in its applicability to 
those cases, the nitrate of silver and opium. Bat there are very many of 
this class of patients who are obliged to have treatment for a long period 
of time. Many of them will progress favorably under the influence of one 
of these combinations for one or two weeks, when they will cease to make 
further improvement. If you persist in giving the same remedies they 
will begin to retrograde, the discharges become again very frequent, and 
the patient of course very much reduced. 

But if, as soon as the patient, who has been improving up to a given 
time, ceases to make further progress in that direction, you immediately 
substitute one of the other preparations, the new impression will very 
generally carry the improvement still further, and the patient will make a 
steady but slow progress in the direction of recovery for a time, and 
again begin to show indications of receding. This is an indication that 
the medicine should be again changed either to the first formula or to the 
third one. Bv thus changing* from one to the other at suitable times, 
always continuing to use o le persistently as long as the improvement 
continues, and by substituting another which will give a little different 
impression, and yet have the same general end in view, you will succeed 
in greatly improving patients, that without such a succession of remedies 
would have ceased to improve and proceeded to an early fatal termina- 
tion. An item of much importance in the treatment of these chronic 
cases of disease is the securing for the patient good air, cleanly and 
healthy surroundings, almost entire rest during a part of each day as 
well as at night in a recumbent position, and a steady, persistent regu- 
lation of the diet on the principles that I have indicated. If all these 
circumstances can be made to co-operate, some one of the formulas 
that I have mentioned will almost always be found greatly to mil - 
gate the suffering of the patient, and to prolong his life, if it does not 
cause positive reparation of the injured structures and lead to recovery. 
In addition, however, to the list of remedies I have already mentioned, 
in some cases where the patients have become much anaemic, I have 
found a powder, composed of the sub-nitrate of bismuth, from three to five 
decigrams (gr. v to viii), sub-carbonate of iron from one to two deci- 
grams (gr. iss to iii) and pulverized opium six centigrams (gr. i) 
given from three to four times a day to produce very decided ameliora- 
tion of the symptoms, and in a few instances apparently turn the scale in 
favor of permanent improvement and ultimate recovery. In a few in- 
stances, also, of somewhat similar character, I have used bromine rendered 
soluble with the bromide of potassium in the proportion of eight minims 
of the bromine, four grams (3i) of the bromide of potassium, in one hundred 
and eighty cubic centimeters (^vi) of water; of which from four to six 
cubic centimeters (3i to 3iss) may be given, further diluted with sugar 
and water, every four, six or eight hours, according to the effect desired. 

In some cases of long standing, where the patients had become ex- 
hausted, the stomach irritable, the mucous membrane of the mouth and 
fauces apthousand tender, 1 have rendered the patients much more comfort- 
able in all respects, by giving frequent doses of an emulsion made in the 
same manner as the turpentine and laudanum emulsion, only substituting 



572 PERITONEAL ENTERITIS. 

the same amount of pulverized gum-benzoin for the oil of turpentine. The 
gum-benzoin thus rubbed up with sugar and tincture of opium will not dis- 
solve in the mixture, but remains suspended only, of which some will fall 
to the bottom while standing, and consequently the mixture should be well 
shaken up whenever it is poured out. But it is devoid of any qualities cal- 
culated to offend the stomach, and has sometimes produced very pleasant 
and ameliorating effects. It may be given in the same doses, and with the 
same frequency as the ordinary turpentine and laudanum emulsion. I 
have now spoken of the strictly inflammatory affections, acute and 
chronic, which are met with in ordinary practice, in the different portions 
of the interior of the alimentary canal, from the mouth to the anus. There 
remain of the digestive apparatus, the exterior or peritoneal covering of 
the intestinal canal, and the important glandular structures in the mesen- 
tery, the liver, spleen, and pancreas yet to be considered. 



LECTURE LV. 



Peritonitis— Peritoneal Enteritis— Their Causes, Clinical History, Anatomical Changes, Diag- 
nosis, Prognosis and Treatment. 

GENTLEMEN: The peritoneum, like the pleura and pericardium, is a 
complete sac, composed of serous membrane, lining the interior of the 
abdominal cavity and reflected over the mesenteric glands and intestines, 
including the upper portion of the pelvic viscera, and the exterior of the 
liver, spleen, and in a less direct manner, the kidneys and pancreas. Like 
the other serous membranes it is composed largely of connective tissue, 
a layer of lymph ducts, a vascular net-work, an abundance of lymphoid 
cells and cana.s, with a i'ree surface of polygonal cells, or what is usually 
called endothelium. The membrane thus composed possesses a high 
degree of absorbing power, taking up readily almost any substance in a 
fluid form, that is placed in contact with its surface. Consequently it 
imbibes actively septic matters, which may be formed in adjacent tissues 
and organs, or that may be derived from perforation and escape of the 
contents of the intestines, stomach or other hollow viscera, with which it 
is connected. It is subject to attacks of inflammation of all grades of 
severity or activity from the most acute and rapidly progressive, to the 
most slow and chronic form of disease. It is subject to acute attacks 
that rapidly involve a large portion or all of the membrane, and in other 
instances it may be circumscribed or limited to a very small part of it. 
The latter cases are what are called circumscribed peritonitis, and usually 
result from the extension of inflammation to the peritoneum from viscera 
previously inflamed, to which the peritoneum is attached — or from per- 
forations that allow the escape of irritating material, and the establish- 
ment of a primary local inflammation of the membrane surrounding the 
perforation. The chronic form of inflammation may occur idiopathically, 
or it may be the sequel of an acute, or subacute attack. And like the 
acute grade of the disease it may be either general, involving the whole 
membrane, or it may be limited to a small portion of it. For practical 
purposes, it is convenient to consider inflammations of the peritoneum 
under three heads: — acute diffuse peritonitis, acute and subacute circum- 
scribed peritonitis, and chronic peritonitis. 



SYMPTOMS. 573 

Acute General Peritonitis. — As an idiopathic affection arising from 
ordinary atmospheric causes, acute inflammation of the peritoneum is of 
rare occurrence. Cases, are, however, occasionally met with arising from 
sudden and severe exposure to cold and wet, excessive exercise and from 
mechanical injuries. But far the larger proportion of cases originate sec- 
ondarily during the progress of inflammation in organs, with which the 
peritoneum is in contact. I have already had occasion to mention that 
in mucous-enteritis, collitis and gastritis, the inflammation not infrequently 
extended during its progress to the peritoneum, and sometimes spread 
diffusely over the surface of this membrane; particularly was this men- 
tioned as frequently occurring in connection with typhlitis and peri- 
typhlitis. It is also liable to occur as the result of all forms of severe in- 
testinal obstruction, whether from irritation of the circular fibers of the 
muscular coat, inducing contraction of the intestine of a tonic and per- 
sistent character, from concretions and tumors, or from positive intussus- 
ception. But among the more frequent causes capable of developing 
rapid and fatal peritonitis, are intestinal perforations either during the 
latter stages of typhoid and typhus fevers, or during the progress of 
chronic gastric ulcers, or perforations of the vermiform process, or of the 
gall bladder and escape of bile, and sometimes though rarely of a rupture 
of the ureter, or of the pelvis of the kidney, or from suppuration in one 
or more of the mesenteric glands, the abscess maturing and perforating 
the peritoneum, and allowing the escape of pus. Similar results some- 
times take place also in abscesses of the liver, perforating the membrane 
covering that organ and allowing pus to escape into the cavity of the 
peritoneum. Cases of general peritonitis have also occurred from the 
escape of injections directed into the uterine cavity, through the Fallo- 
pian tubes into the cavity of the peritoneum. Acute general peritonitis 
also arises not infrequently in the progress of metritis, and sometimes 
from pelvic cellulitis, and almost always accompanies that severe form of 
disease called puerperal fever, or puerperal peritonitis. But as puerperal 
fever proper is a disease arising from a specific cause in connection with 
child-bed, and is fully considered in nearly all works upon midwifery and 
diseases of women, we shall not include it in our further discussion of 
this subject. 

Symptoms. — Acute, general peritonitis usually commences abruptly, 
and in the larger proportion of cases is accompanied in its beginning by 
a more or less distinct chill. Coincident with the occurrence of the chill, 
which is usually of brief duration, there is a sense of soreness and tension 
in the abdomen, with frequent, sharp lancinating pains, with more or less 
sense of heat or burning in the interval between the sharp pains. As the 
sensation of chilliness or the cold stage passes by, the cutaneous surface 
generally becomes dry, and increased in temperature from two to four 
degrees above the normal. The pulse becomes rapidly increased in fre- 
quency, usually numbering from one hundred to one hundred and ten 
per minute, before the end of the first twenty-four hours. It is usually 
rather soft, compressible, as well as frequent, though sometimes it is tense 
and firm under the finger. The respirations are short and increased in 
frequency, being suppressed in some measure by the voluntary efforts of 
the patient, on account of the increase of pain caused by full inspirations. 
As the febrile stage is developed, the pains in the abdomen become, more 
severe, the tenderness to pressure very acute, and all motions of the body 
in turning or moving in any direction increase the pains in a marked de- 
gree. The respirations are stifled on account of the descent of the dia- 
phragm crowding upon the abdominal viscera, causing much increase of 



574 PERITONITIS. 

pain. The bowels are almost always constipated from the time of the super- 
vention of the inflammation or tenderness, there being no disposition to 
further intestinal discharges. Some instances have been observed, indeed 
two have recently come under my own observation, in which immediately 
preceding the supervention of chilliness, and commencement of symptoms 
of local inflammation, the bowels had been evacuated freely two or three 
times. In the later stages of the disease, however, the inflammatory ac- 
tion extends into the coats of the intestines sufficiently to induce, in many 
of the cases, more or less active diarrhoea. The stomach, in the diffuse 
acute peritonitis very generally becomes more or less irritable, and vomit- 
ing in many of the cases is a very troublesome and distressing symptom. 
The contraction of the abdominal muscles in the act of vomiting causes 
very great increase of pain and soreness, and sometimes apparently adds 
much to the prostration of the patient. The urinary secretion is usually 
much diminished in quantity from the beginning of the disease, and red- 
der than natural, very generally voided with little difficulty, but some- 
times with decided pain or scalding". There is usually much thirst ; a 
very anxious expression of countenance, at first a white coat upon the 
tongue, turning more or less brown and dry as the case progresses ; there 
is much thirst and desire for cold drinks, and yet vomiting is often nro- 
voked by the use of the smallest quantity of liquids. The matters ejected 
by vomiting are at first simply the contents of the stomach, but subsequently 
mixed more or less with a mucous or serous fluid, usually colored deeply, 
with the coloring matter of bile, altered by the action of the acids of the 
gastric secretion to a green hue. If the case progresses unfavorably, in 
from three to four days the matters ejected by vomiting become greatly 
increased in quantity, of a dark brown color, and are ejected more by a 
regurgitation, than the ordinary process of vomiting. Occasionally there 
will be indications of blood in the matters ejected. 

And if diarrhoea supervenes in the advanced stage, the discharges are 
usually of a dark brown color, offensive in odor, and also sometimes inter- 
mixed with blood. As the fatal result draws near, the urinary secretion 
is often suppressed entirely, the pulse becomes extremely rapid and feeble, 
the extremities cold and bluish, eyes sunken, expression of countenance 
haggard, the mind inclined to be drowsy and dull, and occasionally, wan- 
dering, or muttering with a low form of delirium. In connection with 
these symptoms the discharges become involuntary, the sphincters re- 
laxed, the chin dropped, the respirations shorter and shorter, until life 
ceases. Death is said to take place from asthenia or exhaustion. In the 
most acute form of the disease, diffuse peritonitis frequently passes 
through its successive stages and terminates fatally in from three to five 
days. Perhaps the average duration of acute cases is from five to seven 
days. In addition to the symptoms that I have already mentioned, ab- 
dominal distension or tympanitis is a prominent and important one. It 
usually commences early after the beginning of the disease, and often- 
times is extreme — the abdomen being distended to such an extent with 
the arrest of gases in the intestines, that the distension is not only pain- 
ful to the patient, but it crowds the liver, stomach and diaphragm up- 
wards to such an extent as to greatly lessen the capacity of the chest, and 
consequently to render the aeration, or oxygenation and decarbonization 
of the blood very deficient. This diminution of the capacity of the chest 
for air, and the consequent failure of the natural function of respiration, 
greatly increases the rapidity of failure in the strength of the pulse, 
developing cold extremities, blueness of the lips and ends of the fingers, 
early somnolency, suppression of urine, and death. More or less of abdom- 



ANATOMICAL CHANGES. 575 

inal distension, and acute tenderness to pressure, — the tenderness and 
pam on pressure being increased in proportion to the depth of the pres- 
sure, — are symptoms that are perhaps more distinctive of this form of in- 
flammation than any other that we have enumerated. While the great 
majority of cases of acute diffuse peritonitis commence in the manner I 
have indicated, by chilliness and an abrupt development of inflammatory 
action or symptomatic fever, there are a few cases in which the disease 
develops gradually, and without marked chill. The patient complains 
of a progressively increased sense of soreness and pain, aggravated by 
pressure and motion of the body, as in walking or upon turning from one 
side to the other, for two, three or even four days before sufficient general 
febrile movement and- feeling of sickness supervene to seriously attract 
the attention of the patient. But when once developed it pursues the 
same general course that we have already described. Again, cases have 
been met with, though very rarely, in which the symptoms of the disease 
were entirely masked or latent ; there being neither any considerable 
amount of pain locally in the abdomen, tenderness, nor any apparent gen- 
eral fever ; and yet the patient became rapidly and fatally exhausted. 

When the disease arises from a local cause, such as perforation of some 
of the hollow viscera in connection with the peritoneum, or from exten- 
sion of inflammation from other parts, there is less liability to chilliness 
at the time the peritoneal inflammation commences, and the local symp- 
toms are usually at first circumscribed — that is, the pain is seemingly 
limited at the outset to the neighborhood or locality, where the perfo- 
ration of the peritoneum or inflamed viscus exists; but the extension may 
be so rapid as to cause diffusion of the inflammation over the whole mem- 
brane, within a few hours after it has established itself at the original 
point of attack. 

Anatomical Changes. — The anatomical changes which take place during 
the progress of acute, diffuse peritonitis are the same in kind that occur 
in acute pleuritis and pericarditis. There is intense injection of the 
vessels of the membrane, causing a deep red color, sometimes bordering 
upon a brown; at other times a greenish hue, with more or less tumefaction 
or apparently increased thickening of the membrane, and accumulation or 
exudation of fibrinous material, lymphoid cells, white corpuscles, and 
more or less serum in the interstitial spaces of the membrane, and sub- 
jacent connective tissue. At the same time there is more or less exuda- 
tion upon the surface of the membrane, in some instances of a plastic or 
fibrinous character organized into white layers of adventitious tissue ad- 
hering to the surface and sometimes causing coils of intestines lying in 
contact to be more or less adherent to each other, and to the in- 
flimed surface. More frequently in addition to a moderate amount 
of this semi-plastic exudation, there is also an exudation of serous fluid, 
containing more or less of pus corpuscles, shreds of a fibrinous material, 
and sometimes enough of the red corpuscles of the blood to give it a red- 
dish appearance. In other instances instead of either a plastic or serous 
exudation, the accumulation upon the surface of the membrane is almost 
entirely purulent. Perhaps the great majority of cases that terminate 
fatally present all three of these inflammatory results coincidently; — * 
namely, fibrinous exudation forming layers upon the surface of the in- 
flamed membrane, with a pretty abundant serous effusion freely inter- 
mingled with pus corpuscles, so as to constitute a sero-purulent accumu- 
lation. When the inflammation causes only a serous exudation, it may 
pursue the same course as any serous exudation into the pleura or peri- 
cardium, namely, absorption and consequent recovery of the patient, 
without leaving any unpleasant setfuelce. 



576 PERITONITIS. 

In those cases, however, in which the accumulation in the cavity of the 
peritoneum is purulent, complete absorption will not take place, and in 
the great majority of cases it will cause a fatal termination. In a few in- 
stances, however, even of purulent accumulations, the serous part of the 
pus has been removed by absorption, leaving a white or yellowish white 
cheesy mass, which has appeared capable of remaining in that condition 
without further change for a considerable length of time. In a few instances 
in which post-mortems have shown the absorption of the serous part of 
these sero-purulent effusions, there has been left a substance closely anal- 
ogous to colloid material. Where there has been plastic exudation, and 
3 r et the inflammatory action subsides without fatal prostration, a slow dis- 
integration of the partially organized fibrine has taken place until it has 
entirely disappeared. But much more frequently it only partially dis- 
appears by this process, and the remainder becoming more highly organized 
remains as new tissue and causes either permanent thickening of the peri- 
toneal membrane, or more frequently permanent bonds of union between 
what would otherwise be free surfaces, — attaching coils of intestine to 
each other, thereby embarrassing the natural peristaltic motion, and 
often inducing colic, and other troublesome intestinal derangements. 
Sometimes these bands of false tissue contract in the process of time 
so as to form constrictions and troublesome obstructions of the bowels, 
and occasionally give rise to an entanglement of loops of intestine 
in such a way as to produce complete strangulation and death of the 
patient atfsome remote period of time from their original formation. 

Diagnosis. — The diagnosis of acute peritonitis is- not difficult. The 
acute tenderness of the abdomen to pressure, the pain being increased in 
proportion to the depth of the pressure, directly associated with increased 
rapidity of pulse, increased temperature, acute lancinating pains greatly 
aggravated by any motion of the body, certainly distinguish the disease, 
even in its early stage, from almost any other morbid condition that can 
be named. And the distinguishing features, both general and local, 
become more prominent as the disease progresses. There are some cases, 
however, of hyperesthesia or morbid sensitiveness from a peculiar con- 
dition of the nervous system, in which there is an apparent extreme sen- 
sitiveness of the tissue over the abdomen, and which might at first be 
mistaken as evidence of peritonitis. But in all classes of cases of myalgia, 
neuralgia or hyperesthesia, the tenderness has this distinctive character: 
that it is superficial, and the patient gives some evidence of pain and 
shrinks from slight touches upon the surface, as much as he does from 
steady firm pressure. And in almost all such cases, if the palm of the 
hand is placed upon the abdomen and steady continuous pressure made, 
it is fou.id that the patient complains no more than he did from the 
slightest touch of the fingers upon the surface. The reverse of this, how- 
ever, is true of peritonitis. In all forms of inflammation of the peri- 
toneum, very slight pressure upon the surface creates but little uncom- 
fortable sensations, while the more firm and deep the pressure the more 
acute the pain the patient suffers. Another characteristic of peritonitis 
which aids in maintaining the diagnosis is the rigidity of the abdominal 
muscles. 

This is more particularly noticeable in the recti muscles before the ab- 
domen has become too greatly distended by tympanitis. If you thus give 
due. attention to the character of the tenderness, and the effects of deep 
pressure as distinguished from mere superficial touches, the condition of 
rigidity or non-rigidity of the abdominal muscles, and remember that in 
connection with this, in the inflammation of the peritoneum, there is more 



PROGNOSIS. 577 

or less general constitutional disturbance, such as pyrexia, unusual ra- 
pidity of pulse, a correspondingly short, stifled and frequent respiration 
and occurrence of pain on any attempt at such motion of the body as will 
disturb the abdominal cavity, you will not be liable to confound acute 
peritonitis with any other variety of disease. 

Prognosis. — The prognosis in acute diffuse peritonitis should always be 
given with caution! If the disease is recent and from exposure to cold or 
wet, or from ordinary accidents in previously healthy conditions of the 
system, under judicious management a large majority of cases will re- 
cover. So, too, when it originates simply from extension of the inflam- 
mation from other organs with which the peritoneum is in contact, there 
is a strong probability that the case will terminate favorably, provided 
the primary disease can be controlled; as the same means which have 
answered for its control, will be sufficient also to limit and finally over- 
come the peritonitis. Cases to which I have alluded as favorable in their 
prognosis are usually accompanied only by plastic or sero-plastic exuda- 
tions. But when the disease occurs as the result of perforations of the 
intestines, or any of the hollow viscera or parts connected with the per- 
itoneal membrane, or from absorption of septic or poisonous material from 
disease or suppurative processes in any of the viscera, or in the advanced 
stage of renal disease and dropsical effusions, the prognosis is extremely 
unfavorable. In nearly all such cases the inflammatory products assume 
early the form of pus. And whenever accumulations, taking place in the 
peritoneal cavity, are purulent, the patients become early exhausted and 
very rarely recover. Still there are some instances in which the inflam- 
mation supervenes from direct perforation and escape of material from the 
intestines or from some of the hollow organs in connection with it, and 
yet exudation thrown out rapidly around the point of opening causes so 
early an adhesion to the parts lying in contact as to set bounds to the 
further escape of material through the perforation, and also to prevent 
whatever suppuration takes place from becoming diffused through the 
whole of the peritoneal surface. Thus the inflammation is purely circum- 
scribed, and the exudative material is limited to the small space in 
immediate connection with the original opening. Such cases have occa- 
sionally ended favorably. Sometimes by the reabsorption of the accumu- 
lated products of the inflammation, more frequently by enlarging the 
opening and permitting their escape into the intestine and discharge 
through the alimentary canal, or by the formation of a circumscribed 
accumulation of pus capable of being early recognized by palpation, and 
removed either by aspiration or by free incision through the abdominal 
walls. Such instances, however, are comparatively rare. 

When around a circumscribed inflammation, plastic material has been 
thrown out, adhesions have been formed, and at the same time serous 
effusions have occurred from the inflamed surface, these effusions, in- 
stead of being allowed to enter into the general cavity of the peritoneum, 
are limited by the adhesions to a part of the cavity, and thus constitute 
what has been called an encysted ascites. This is capable of reabsorption 
like any other serous fluid, allowing the patient ultimately to recover, or 
if reabsorption does not occur, and the parts become distended sufficiently 
to reveal the true nature of the case, paracentesis in the ordinary manner, 
or aspiration may cause its removal, and contribute to the patient's ulti- 
mate recovery. The danger, however, from aspiration, or incisions, and 
from the use of the ordinary trochar in such a circumscribed accumulation 
is in the liability of having the instruments perforate some portion of the 
37 



578 PERITONITIS. 

intestines. This must be kept in mind as an important item where such 
operations may be deemed advisable. 

Treatment. — When acute or subacute peritonitis occurs from acci- 
dental or atmospheric causes in previously healthy conditions of the sys- 
tem and the physician is called early, advantage may very generally 
be derived from a moderate local bleeding by leeches. It is seldom that 
venesection will be required, though in some instances where the pulse is 
full and firm under the fingers, the symptoms have supervened rapidly, 
and the abdomen become extremely tender with great pain, it may be ad- 
missible to practice one free venesection at a very early period in the prog- 
ress of the disease. I hardly remember a case presenting these features 
sufficiently to justify or require the use of the lancet, but when called 
early I have derived very much advantage from pretty free application of 
leeches, allowing the blood to flow after the leeches have fallen off, en- 
couraging it by the application of cloths dipped in warm water, and subse- 
quently keeping the abdomen covered with warm narcotic fomentations. 

The leading object of the treatment is to directly arrest the inflamma- 
tory process, less by diminishing the vascular fullness than by overcoming 
the morbid excitability of the inflamed structure by the use of anodynes and 
sedatives. Not only do anodynes here act in the direction of overcom- 
ing the morbid excitability of the inflamed structure, but they are most 
efficient agents for putting the inflamed parts at rest, a condition very es- 
sential in the treatment of all inflammatory processes. Motion of the 
parts and peristaltic motion of the bowels especially, greatly increases the 
pain and the intensity of the inflammatory process. Hence to put the 
bowels entirely at rest and keep them so, until the inflammation has 
abated, is one of the essential features of judicious treatment. And one 
of the most common errors that is committed consists in the early admin- 
istration of evacuants which tend directly to increase the peristaltic motion 
under the delusive idea, that it is essential to empty the alimentary canal. 
This causes patients also to be disturbed in getting up and moving for 
the evacuations, thereby greatly aggravating their condition instead 
of affording relief. In the cases to which I have just alluded, where 
the patient is not previously in a depraved condition of health by prior 
disease, or constitutional impairments, I have preferred the administration 
to adults, during the first twenty-four or thirty-six hours of full doses of 
opium in connection with small doses of mercurials; more particularly of 
the mild chloride or calomel. From two to three centigrams (gr. ^ to ^) 
of the sulphate of morphia, and six centigrams (gr. i) of calomel in 
the form of a powder, with a little white sugar, may be given every two, 
three or four hours according to its effects, beginning with a shorter time 
till the patient has been brought sufficiently under the influence of the 
medicine to be free from pain and decidedly inclined to sleep. If the ad- 
ministration of these powders is commenced in direct connection with the 
application of leeches, and later is followed by narcotic fomentations as I 
have indicated, there are many cases in which the first three doses will 
cause almost entire relief of the pain and restlessness of the patient, and 
induce the beginnings of sleep. As soon as this effect is produced the 
interval between the doses should be increased, first to three hours, then 
to four hours, and kept only at such intervals as will serve simply to per- 
petuate the restful condition of the patient without inducing profound 
stupor. The result will usually be that in from twenty-four to forty-eight 
hours, under sufficient narcotic influence to produce the degree of rest I 
have indicated, the pulse will become slower, the temperature reduced, the 



TREATMENT. o79 

skin covered with a warm moist perspiration, and the local pains and ten- 
derness greatly diminished. When these results have been obtained do 
not immediately risk a reversal of the favorable aspect of the case by at 
once resorting to cathartics, but allow the bowels still to remain at rest 
leaving out calomel, and continuing the opiate preparation alone at just 
such intervals as will keep the patient in a comfortable condition of rest. 
At the same time that calomel is omitted, give in addition to the an- 
lvne in the interval between the doses of it, some diuretic. For this 
purpose we have nothing better than an equal mixture of the liquor ammonii 
acetatis and nitrous ether, four to eight cubic centimeters of which maybe 
2f i ven, diluted with a little water, between each of the doses of the anodyne. 
If the case progresses favorably as most of them will, of the kind I have 
iiow under consideration, by the end of the third day the tenderness will 
have almost entirely disappeared from the abdomen, there will be little or 
no tympanitis, the pulse will have returned nearly to its natural standard 
and with the exception, in some instances, of a mild degree of secondary 
nausea from the etfects of the anodynes, the patient will be entirely com- 
fortable. Where six centigrams (gr. i) of calomel have been given in 
connection with the first five or six doses of the anodyne, the bowels will 
now in many of the cases begin to move spontaneously, not with pain but 
with entire ease; the discharges being usually semi-fluid, or only moder- 
ately consistent, and pretty copious, and where they occur not more than 
two or three times, they need not be interfered with. But if the number 
of the discharges increase, become more thin, and are accompanied with 
some pain in the abdomen, measures should be taken immediately to 
arrest their further occurrence, and put the intestines more perfectly at 
rest. 

This may often be done by renewing a little more frequently the doses 
of morphine, or still better, so far as my experience goes, by giving in 
place of the morphine what I have frequently mentioned to you as the 
ordinary turpentine and laudanum emulsion, in doses of four cubic centi- 
meters (fl. 3i) after each evacuation until they have entirely ceased. 
After the bowels have been freely moved, either spontaneously or by 
warm water enemas thrown into the rectum, if there appears to be no ten- 
dency for loose discharges and pain to continue, full convalescence 
ensues, and the patient requires little other treatment than rest, and 
a very mild unstimulating diet, taken in small quantities for three or 
four days. At the end of that time, if no renewal of symptoms occur, he 
may be allowed to rise from the bed, and occasionally to take exercise. 
But the convalescent in all such cases should be carefully guarded 
against all excesses both in exercise, as walking, or motions that jar the 
abdomen, and in indulgence in promiscuous diet. But where cases are 
not seen quite as early as I have indicated and the disease has made 
more progress before coming under observation, it may not be judicious 
to apply leeches or practice any local bleeding. But the warm narcotic 
fomentations may be applied over the whole abdomen, and opiates may be 
administered, each of the first three or four doses being combined with 
six centigrams (gr. i) of calomel. The anodyne should be given in suffi- 
cient doses with sufficient frequency to bring the patient fairly under its 
sedative influence and place him at rest as early as practicable without lead- 
ing to profound narcotism. The combination of liquor amrnonii acetatis 
and nitrous ether to encourage continued action of the skin and kid- 
neys may, if retained by the stomach, be given between the doses of the 
anodyne. And to prevent the stomach from becoming irritable and 
the supervention of troublesome vomiting, the patient should be encour- 



580 PEKITONITIS. 

aged to take only bits of ice to satisfy thirst and a single spoonful at the 
time of bland nourishment such as lime water and milk, or some one 
of the animal broths. After the first twenty-four hours of the treatment, 
the calomel which had been incorporated with the first four or five doses 
of the anodyne should be omitted. The anodyne and the diaphoretic 
may be continued, and if the tympanitis increases, the abdomen may 
be frequently painted over either with a liniment of camphorated soup 
and iodine in such proportion as to render it decidedly stimulating to 
the surface, or there may be applied freely over the surface a mixture of 
olive oil and oil of turpentine, the latter being in such proportion as will 
produce an active irritation. These applications may be repeated 
once in three or four hours, and in the intervals the narcotic fomentatioi s 
may be kept over the abdomen. These, however, must be made light, 
for anything heavy especially thick poultices over the tender abdomen 
usually increase the suffering of the patient more than they do good. If 
these measures succeed in arresting the further progress of the disease, 
the patient may remain at rest two or three days during which the pulse 
will become slower, the temperature diminish and all the phenomena 
of inflammation disappear. 

If now spontaneous evacuations do not occur, steps may be taken 
to cautiously induce movement of the bowels by enemas as I have 
already described. But the administration of cathartics is entirely in- 
judicious, on account of the danger of renewing the pain in the abdomen 
and of causing the return of all the phenomena of the peritoneal inflam- 
mation. And sometimes the operation proceeds to such a degree of pro- 
fuseness as to hasten the patient into an early collapse. Consequently 
unless evacuations spontaneously occur it is far better to wait, for a whole 
week, than it is to resort to anything more than mild enemas until con- 
valescence is well established. My experience has been, that in a large 
proportion of cases spontaneous evacuations occurred before the end of 
the third or fourth day. It is much more frequently necessary to in- 
stitute measures for limiting and ultimately arresting these spontaneous 
evacuations than it is to give cathartic medicines of any kind. One of 
the embarrassments that you will meet with in the treatment of acute 
peritonitis, is the excess of irritability of the stomach. And for the first 
two or three days you will frequently find it impracticable to adminis- 
ter a sufficient amount of anodyne by the stomach to obtain the 
quieting effects that you desire. In such instances hypodermic injections 
of morphine should be resorted to, allowing the stomach to remain entirely 
at rest. Always use hypodermic injections, however, in safe doses, and 
take the trouble of repeating them rather than risk doses so large as to 
produce excessive narcotism, especially when the abdominal distension 
may be, at the same time, so great as to have limited the respiratory func- 
tion and consequently the oxygenation of the blood. In such conditions 
the subcutaneous injection, of even ordinary doses of morphine have been 
known to speedily produce so profound a narcotism as to prove fatal 
within a few hours. And yet the judicious use of subcutaneous injections 
in some of these cases becomes necessary and highly valuable. It is true 
that in some they may be avoided by the use of anodyne enemas. But 
these are less likely to be retained, are slower in producing their effects, and 
in other respects less reliable than the use of the remedy subcutaneously. 
It is a frequent practice to apply blisters extensively over the abdomen 
in peritonitis, at that stage when effusion is liable to commence, or what 
is called, the second stage of the disease. I have sometimes seen decided 



CHRONIC PERITONITIS. 581 

ad vantage apparently derived from their use; but in the great ma- 
jority of cases it is sufficient to apply the stimulating embrocations 
and liniments that I have already mentioned. If the acute stage 
passes bv and partial convalescence supervenes, leaving the abdomen 
enlarged from the accumulation of serous effusions, as sometimes happens, 
it may become desirable to apply a succession of small blisters over the 
abdomen in connection with the internal use of suitable doses of the 
iodide of potassium sometimes combined with digitalis. The use of 
iodide of potassium in combination with digitalis internally, and moderate 
counter-irritation externally, will also constitute the best remedies when 
the inflammation assumes a chronic form. If the amount of fluid in the 
peritoneal cavity is large and there is manifest but little disposition to 
diminish under the use of these remedies it may be removed by the aspirator 
or by the ordinary method of paracentesis abdominis, and its reaccumulation 
retarded if not entirely prevented by a continuance of the remedies I 
have already named, after the withdrawal of the fluid. If in the progress 
of the treatment of acute peritonitis the remedies I have indicated fail to 
arrest the disease, and the pulse becomes extremely rapid and feeble, the 
extremities cold and blue, the respirations short and frequent, the mind 
dull and wandering, the abdomen more or less distended, there is little 
prosoect that the patient will recover, under any kind of treatment what- 
ever. Opiates under such circumstances must be given more cautiously; 
and in conjunction with their moderate continuance, the patient may 
derive some benefit from the use of such diffusible stimulants as car- 
bonate of ammonia, camphor, caffeine and theine; and digitalis as a tonic 
to sustain the heart's action. Stimulating embrocations over the abdomen 
may also be continued, and a vigilant administration of nourishment. 
Tablespoonful doses of wheat flour and milk gruel, beef tea, or other an- 
imal broths, and the frequent administration of one or two spoonfuls of 
warm tea or coffee such as is usually taken upon the table, will constitute 
the best means of support. 

It is almost the universal practice in these cases to resort to the free 
use of alcoholic remedies, under the idea that these will aid in sustaining 
the vital forces and in preventing fatal exhaustion. I have never seen an 
instance, however, in which I could perceive the slightest beneficial effect 
from their use. In the cases of limited, or circumscribed peritonitis, 
if the inflammatory symptoms abate and yet leave accumulations, either 
of a serous or purulent character, the first will generally disappear by 
absorption under the influence of the measures I have indicated. If not, it 
can be removed by aspiration. In those cases where the accumulations 
are purulent aspiration may be resorted to, and if the pus is found to be 
too thick to pass the aspirator needle successfully and freely, larger 
openings may be made, the pus discharged, and the subsequent antiseptic 
treatment judiciously carried out with some prospect of success. Yet 
many such cases will ultimately fail under continued suppuration and 
die from exhaustion. What I have now stated in regard to the varieties 
of acute general or diffuse peritonitis, has included so much concerning 
the circumscribed form of the disease; and the management of this class 
of cases is so directly parallel in kind with that of the more diffuse, as to 
make a separate consideration unnecessary. 

Chronic Peritonitis. — Chronic inflammation of the peritoneum may be 
the sequel of an acute or subacute attack, or it may originate independ- 
ently of any preceding acute stage. A large proportion of the acute 
attacks accompanied by suppurative action and accumulation of pus or 
pus mixed with serum in the cavity of the peritoneum, degenerate into the 



582 CHRONIC PERITONITIS. 

chronic form, and although often continuing a considerable length of time, 
ultimately terminate fatally. Many of those that I have mentioned as cir- 
cumscribed inflammations of the peritoneum also terminate in subsidence of 
the general febrile symptoms, while the membrane will remain more or less 
thickened, with increased vascularity, some degree of tenderness and an in- 
creased accumulation of the inflammatory products so as to constitute, strict- 
ly speaking, a chronic form of the disease. Occasionally cases may be met 
with, in which chronic inflammation is developed in the peritoneum, or in 
some portion of it, as the result of mechanical violence, induced by falls or 
blows, but more frequently by far the cases of chronic inflammation of this 
membrane originate not from any acute attacks, but are from the beginning 
of that low grade called chronic, and having for their causes either the effu- 
sion of serous fluid into the cavity of the peritoneum from obstructions to 
the portal circulation, as in diseases of the liver, or in connection with gen- 
eral dropsy as in renal disease; the inflammatory action being secondary 
to the dropsical accumulations in such instances. Or they may originate 
from tuberculous deposits more frequently in that part of the mesentery 
covering the omentum, meso-colon and the exterior of the liver and 
spleen. In a very large proportion of the cases of general milliary tuber- 
culosis, more or less deposits take place in the portions of the peritoneal 
membrane just mentioned, sometimes without exciting sufficient inflam- 
"matory action to attract attention, and in others being accompanied with 
a slow, insidious development of inflammation, exudation and effusion, 
sufficient to fill up the peritoneal cavity. In some patients of scofulous 
constitution, especially in early childhood the mesenteric glands become 
involved in hypertrophy and casaous degeneration in the same manner as 
the lymphatic glands in the neck or in the arm pits, and during their prog- 
ress especially in the stage of softening, sufficient inflammatory action 
is set up to involve the peritoneum, entering into the formation of that 
part of the mesentery, in which the glands are located. But this form of 
disease was sufficiently described when speaking of the various conditions 
of scrofula in its local developments throughout the whole system. 
Another cause of chronic peritoneal inflammation is the formation of 
cancerous nodules in the omentum and involving the peritoneum in their 
progress, if not primarily originating in that membrane. Some of the 
cases of scirrhus of the pylorus, involve also more or less inflammation of 
the adjacent peritoneum, and the same is true when scirrhus exists in the 
liver, or in the spleen, near enough to the surface to involve the perito- 
neum covering them. 

Symptoms. — When chronic peritonitis follows as the sequel of the 
acute form of the disease its symptoms consist chiefly of distension of the 
abdomen from accumulations of more or less serous or sero-purulent fluid 
accompanied by thickening of portions of the membrane and tenderness 
to pressure, particularly in circumscribed places. The pulse is moderately 
accelerated, the respiration usually shorter and quicker than natural, 
owing more to the mechanical impediment to the descent of the diaphragm 
than to any other cause. The skin is dry, and the temperature generally 
elevated two or three degrees in the afternoon and evening, while in the 
morning it falls to the natural standard. There is progressive loss of flesh 
and strength, impairment of appetite, scantiness of urine and a variable 
condition of the bowels, they being sometimes costive, and at others too 
loose, and in many cases, constipation and diarrhoea alternate with each 
other at frequent intervals. Under direct examination of the abdomen in 
such cases, in addition to tenderness on firm pressure, there is in most of the 



SYMPTOMS. 583 

cases, a fooling of inequality in different portions of the abdomen, some 
places being harder and more prominent, apparently from the thickness of 
portions of the peritoneal membrane lining the abdominal walls. Also 
more or less dullness on percussion and usually plain fluctuation, indicat- 
ing the existence of fluid. 

The dullness on percussion and the fluctuation by palpation is most 
evident in the most dependent parts of the abdominal cavity, according 
to the position of the patient. In lying upon the back there will be fre- 
quentlv well marked tympanitic resonance in the epigastrium and portions 
of the umbilical region, while the hypochondrium and lumbar regions are 
entirely dull, and afford plain fluctuation. After the disease has as- 
sumed a strictly chronic form, there are not usually severe pains, and yet 
most cases will be characterized by moderate lancinating pains at inter- 
vals, especially when the patient has attempted to exercise or to make 
any considerable movements of the body. There is also a sense of in- 
creased heat in the abdomen in the majority of cases. Frequently there 
is sympathetic disturbance of the system, imperfect digestion of food, 
occasional vomiting, particularly in association with the appearance of 
diarrhoea in the advanced stage of the disease. When the chronic peri- 
tonitis has resulted as a secondary affection in the progress of either renal 
or hepatic diseases, inducing a dropsical condition of the system, the 
evidences of the peritoneal inflammation are often very obscure — the 
prior disease having already debilitated the patient, altered the condition 
of the blood, and induced in the renal cases general dropsy, and in the 
hepatic, more or less circumscribed accumulations in the peritoneal cavity; 
all the symptoms are very apt to be referred to the original disease, and 
yet close inquiry will show, that whenever the peritoneal membrane 
actually takes on inflammatory action, there is an increase of febrile move- 
ments, accelerating the pulse beyond what it had been in connection 
with the previous disease, causing more or less increased sense of sore- 
ness, and sometimes sharp pains throughout different places in the ab- 
domen, with tenderness to pressure, especially in particular regions of the 
abdominal cavity, and more rapid distension of its walls from the 
accumulations of fluid within. The patient almost always finds great 
difficulty in turning from one side to another, without feeling a sore pain 
run deeply through the abdomen, and attempts to walk also generally 
give rise to feelings of sore pain from the concussion. In most such cases, 
the effusion into the cavity becomes so great in a few weeks, or months, 
that the diaphragm with the liver and spleen are crowded strongly up- 
ward, trespassing upon the capacity of the chest, and so far interfering 
with the expansion of the lungs in inspiration as to cause great incon- 
venience to the patient, from shortness of breath, sense of suffocation or 
oppression, and often a relaxation of the skin with cold perspiration, blue- 
nessof the lips, coldness of the extremities, inability to recline in the hor- 
izontal position, or to assume any except one nearly upright. In such cases 
usually the appetite is lost, the urine becomes nearly suppressed, and 
unless relief is obtained by removing the accumulated fluid, universal 
dropsical infiltration takes place into the tissues, causing general oedema 
and an early death. In other instances before this extreme interference 
with the caj)acity of the chest and the respiratory function, the patient 
becomes very much emaciated, apthous ulcerations appear in the mouth 
and fauces, all food becomes distressing to the stomaoh, or is rejected by 
vomiting, a wasting diarrhoea supervenes, and he dies from asthenia, 
rather than from interference with the respiratory process. When 
chronic peritonitis arises from tubercular deposits in the mesentery or 



584 chronic peritonitis. 

or mesocolon, or any of the parts connected with the peritoneum, the early 
symptoms are often exceedingly obscure. Patients most generally, for a 
considerable length of time, complain only of irregular pains in the ab- 
domen, sometimes only momentary and sharp, at other times rather dull, 
or simply of a sense of soreness whenever from attempts at any sudden 
movements of the body the abdomen is jarred, coupled with a progressive 
loss of flesh, a sense of weakness, a quick rather small and compressible 
pulse, a slight elevation of temperature during the middle and latter part 
of the day, accompanied by more or less dryness in the mouth and fauces, 
less than the natural secretion of urine, a fickle or variable appetite, 
an equally variable condition of the bowels, being sometimes consti- 
pated and sometimes the reverse, and after from one to three months 
of these equivocal moderate symptoms the abdomen is found to 
be enlarging. In most instances percussion and palpation will 
readily determine that such enlargement is owing mainly to an ac- 
cumulation of fluid. Sometimes, though rarely, the tubercular form of the 
disease will be accompanied by sufficient enlargement of some of the 
mesenteric glands, or by sufficient accumulation of tubercular masses 
with thickening of the membrane lining the abdominal walls, or of 
the omentum superficially, to be felt as hard bodies through the walls of 
the abdomen. And while detecting by manipulation or palpation the ex- 
istence of such bodies there is also readily revealed more or less fluctua- 
tion of fluid and dullness over the more dependent parts of the abdominal 
cavity. But many of the cases are not accompanied by either sufficient 
accumulations of tuberculous deposits or enlargement of the glands in the 
abdomen to present any tumor that can be detected by an external ex- 
amination. It is true in a very large proportion of these cases tubercular 
deposits are not limited to parts in the abdomen, but exist at the same 
time in the pulmonary tissue, or in the liver, or both. When the lungs 
are involved, physical exploration will usually detect their existence, if 
the physician's attention is turned in that direction. And finding actual 
tubercular deposit in the lungs or any other portions of the system, at 
once would render it highly probable if not certain that the abdominal 
symptoms to which I have alluded, also originated from tubercular de- 
posits in connection with the peritoneal membrane as already described. 
And even in cases where there is no appreciable deposit in the lungs, if 
the patient is in the early part of life, and possesses a strong hereditary 
tendency to scrofulosis or tuberculosis as indicated by family history and 
symptoms, and the symptoms referable to the abdomen that I have de- 
scribed exist, it would justify the inference that they originated from 
tubercular deposits. When it has advanced far enough to occasion any 
considerable amount of serous or sero-purulent accumulations, then all the 
physical signs that were described in speaking of accumulations from the 
more acute form of the disease, equally characterize these cases. 

That chronic peritonitis does occur from the localization of the tuber- 
cular deposits in the peritoneum and other parts in the abdomen, I have 
seen sufficient clinical proof. During the present college term there has 
been a patient in the hospital for a number of weeks, a lad) T about thirty- 
five years of age, who was admitted with the impression that she had an 
ovarian tumor, and evidently entertaining the hope that it might be re- 
moved by the ordinary operation of ovariotomy. Having my attention 
directed to the case on account of some cough and expectoration of a suspi- 
cious character, I found on careful physical exploration, plain evidences 
of extensive tubercular deposit in the upper and middle portions of both 
lungs, and one or two points commencing the second stage of their prog- 



SYMPTOMS. 585 

ross. And it was evident from the examination of the abdomen, that 
the distension there was occasioned not by ovarian cysts, but by actual 
accumulation in the peritoneal cavity, although at two or tlnve places 
deep pressure would apparently bring the points of the fingers in contact 
with hard bodies. In the progress of this case the patient became much 
oppressed in breathing both from the fullness of the abdomen, which 
impeded the descent of the diaphragm, and from the disease in the 
lungs themselves. The abdomen presented well marked fluctuation. I 
thought to give temporary relief to the patient by evacuating the fluid 
contents of the peritoneum by the ordinary operation of paracentesis-ab- 
dominis. I introduced a good-sized trochar withdrawing the styllet but no 
fluid flowed. And yet the impression as it entered the abdominal cavity 
w T as perfectly characteristic of entering a fluid, and at the point of 
its introduction no solid body could be detected. Introducing an 
ordinary probe through a canula no resistance was found at the en- 
trance of the canula, and on twirling it a little there came out a small 
quantity of a gelatinous mass or semi-fluid substance thicker and more 
gelatinous than the albumen of the egg. By continued manipulation, and 
pressure upon the abdomen and especially aided by the sudden pressure 
produced by the coughing of the patient, several ounces of this gelatinous 
material were withdrawn, which caused a considerable lessening of the 
previous tenseness of the abdominal walls. On withdrawing the styllet and 
canula, the cough continued and forced more of this material through the 
opening for the next hour — making perhaps in all that was withdrawn eight 
or ten ounces. This, however, was only a very small proportion of the quan- 
tity contained within. -No inflammatory action followed withdrawal or this. 
The lungs were so much involved, that it was improper to give the patient 
any encouragement about ultimate recovery by any operative procedure, 
she therefore returned to her friends. This illustrated what sometimes 
develops in these cases of chronic peritonitis, namely: filling up of the 
abdomen more or less with a fluid mass so nearly of a gelatinous or 
thick consistence as to be incapable of removal through ordinary proc- 
esses, either by the aspirator, or tapping with the trochar. In another 
instance of a girl fourteen years of age, the tubercular disease involved 
both peritoneum and mesenteric glands. Some of the latter after the ab- 
domen had become much distended by sero-purulent fluid, containing 
flocculi or masses of fibrinous material which had separated from a portion 
of the colon to which they had been adherent, continued to suppurate 
until perforation of the walls of the intestines took place, and thus dis- 
charged the contents of the abdomen through the bowels; affording for a 
time a sensible degree of diminution in its size. The hectic, emaciation, 
and other symptoms continuing, in a few months the patient was worn out, 
when the post-mortem revealed what I have just described; namely, 
granular tubercles covering the surface of the peritoneum, throughout the 
whole of the omental part,of the meso-colon, and nearly the whole mass of 
mesenteric glands in different stages of enlargement and degeneration. 
Some being actually converted into purulent abscesses, and one larger 
gland, which had constituted an abscess, was collapsed, presenting more 
the appearance of a sac, the inner surface constituting the walls of the 
abscess, communicated still with the upper portion of the sigmoid flexure 
of the colon. 

When chronic peritonitis arises from the existence of malignant 
or cancerous disease within the abdominal cavity, the symptoms so 
far as they depend upon peritoneal inflammation, do not differ materi- 
ally from those I have just described as occurring in connection with 



5S6 CHRONIC PERITONITIS. 

tubercular deposits. There is the same obscure beginnings, ending 
after a while in the accumulation of fluid, more rapid distension of the 
abdomen, accompanied by well marked fluctuation, and usually before 
the walls of the abdomen become too tense, or the accumulated fluid 
too large in amount, the existence of a cancerous tumor, can be more cr 
less readily felt through the abdominal walls. Some writers have claimed 
that cancerous disease does not originate, or commence primarily, in any 
part of a serous membrane; particularly those who adopt the theory that 
all cancers originate in the epithelial structures; serous membranes hav- 
ing no proper epithelium, but only a layer of polygonal cells or endothe- 
lium. The evidence, however, favors the doctrine that sometimes, though 
rarely, cancerous developments do occur in the endothelial cells them- 
selves; constituting properly an endothelioma, instead of an epithelioma. 
The distinction, however, is of little or no practical importance, as the 
results would be the same. The diagnosis between chronic peritonitis 
associated with tuberculosis from that associated with carcinoma or any 
variety of cancer depends not so much upon the symptoms belonging to 
the diseased peritoneum, as to those which belong to the primary affec- 
tion. The distinctions are precisely those existing between the cancerous 
cachexia, with more isolated and harder tumors where tumors can be 
detected, and the tuberculous diathesis with the evidence of tubercular 
deposit generally distributed throughout many of the structures, instead 
of being limited to some one region, or to some one hard tumor. 

Still another form of chronic inflammation of the peritoneum has been 
described as a hemorrhagic variety. This appears to be a rare affection 
occurring in the peritoneum, corresponding in its anatomical characters 
closely with what is called pachymeningitis in the serous membranes of the 
brain. There is first dilatation of the vessels in little patches on the 
peritoneum, then ruptures occur, and the escape of small quantities of 
blood, followed by sufficient inflammatory action, usually to throw out a 
layer of false membrane, limiting the diffusion of blood and constituting 
a strictly circumscribed inflammation, which is often accompanied by very 
obscure symptoms, and from which the patient apparently recovers in a 
little time. And the same recurs again and again at different intervals 
until finally a sufficient portion of the membrane becomes involved to 
induce serous effusion, and all the phenomena of abdominal dropsical 
accumulations. When the water is withdrawn it is very generally found 
tinged with blood, or contains an appreciable number of red corpuscles, 
and as its tendency is to reaccumulate, the patient becomes gradually 
exhausted, either from the extent of the accumulation, or the pressure of 
it upon the thoracic cavity and other important organs. If it is with- 
drawn by tapping or aspiration to avoid the distressing effects of over- 
distension, the withdrawal of the nutritive elements of the blood from 
continued exudation into the peritoneal cavity will lead ultimately to 
general exhaustion, impairment of function, universal dropsical infiltra- 
tions and death. 

Prognosis. — From the description I have given of the various forms of 
chronic inflammation of the peritoneum, you will perceive that many cases 
tend to an ultimate fatal termination. It may be said that all the cases 
arising from tuberculosis, cancers, renal and hepatic diseases are incurable. 
Their progress may be retarded, temporary relief may often be obtained 
by removal of the accumulated fluid in the abdominal cavity either by 
aspiration or tapping; but the diseases which have given rise to the peri- 
toneal trouble, being themselves incurable, there is an inevitable tendency 
to a fatal termination. Tne same may be said of such cases as originate 



PROGNOSIS. 587 

in connection with either general dropsy from cardiac and renal disease 
or from direct obstruction of the portal circulation by cirrhosis or other 
structural diseases of the liver. But in cases which have originated from 
moderate subacute and acute attacks in which no suppuration has oc- 
curred, but simply thickening, and continued congestion of the peritoneal 
membrane, accompanied by more or less serous effusion into the abdominal 
cavity, frequently accompanied by a moderate degree of plastic exudation 
which form patches of organized membrane, and sometimes constitute 
bands of adhesion between different coils of intestine, or between the 
surfaces of the peritoneum lying in contact with each other, there is a 
possibility of the patient's recovery, by the use of such remedies as usual- 
lv favor a disintegration and removal of inflammatory products, and a 
careful support of the nutrition of the patient. The inflammatory prod- 
ucts existing in the case may be removed by absorption, nutrition re- 
maining active, no new accumulations take place, and the patient remains 
well. Quite as frequently, however, even in these cases, the patient does 
not make a permanent recovery. 

Remedies for a time lessen the amount of serous accumulation, render 
the patient much more comfortable, but on the recurrence of every excess 
of exercise, exposure, or accident that is calculated to disturb the abdom- 
inal cavity the symptoms are renewed, new accumulations take place 
until the peritoneal membrane becomes permanently indurated; consti- 
tuting substantially a sclerosis or hypertrophy of the connective tissue en- 
tering into it — in which condition a continuance of the process of exudation 
sufficient to renew the serous accumulations within a few weeks has oc- 
curred, every time they are evacuated either by aspiration or tapping. 
And yet such patients will occasionally live for many years. I have one 
still in the wards of the hospital; a woman about forty, or between forty 
and forty-five years of age, who was admitted to the hospital about 
sixteen years since. At the time of her admission, the abdomen 
was enormously distended by a serous accumulation. It had been 
allowed to go on increasing until the umbilical region had given way, 
and a large umbilical, hernial protrusion had taken place. The patient 
was not much emaciated: had little or no general febrile symptoms or in- 
creased heat, but was suffering extremely from the crowding of the dia- 
phragm upwards, and from the great weight of the abdomen. Being unable 
to get a very accurate history of the case, and the dropsy being entirely cir- 
cumscribed or limited to the abdominal cavity, with no cedematous infiltra- 
tion into the feet, ankles or any other part, I was lead to suppose that it 
originated from some disease of the liver; most likely the early stage of 
cirrhosis. But for temporary relief, I introduced an ordinary trocbar 
through the abdominal walls, withdrew the styllet and drew off through 
the canula two large wooden pails full of a very heavy thick or serous 
fluid only slightly turbid. When the abdomen was empty I could detect 
no evidence of any tumor in any part of it, certainly no evidence of en- 
largement of the liver or spleen, neither was there indication of any con- 
siderable contraction of the liver as in cirrhosis. There was slight 
tenderness on deep pressure, as by pressing toward the back parts of the 
abdomen against the meso-colon, but it was by no means strongly marked. 
The reaccumulation of fluid was slow, but at the end of six months, it 
had again become sufficient to be very troublesome to the patient, and 
again we resorted to tapping. She has remained in the hospital 
requiring to be tapped pretty regularly twice a year, the shortest interval 
being five months, the longest seven between the tappings, until she has 
now had thirty-four tappings, during a period of sixteen or seventeen 



588 CHRONIC PERITONITIS. 

years. The only changes that have taken place are a little increased 
paleness, from diminution of the red corpuscles of the blood, and progress- 
ively increased dryness and harshness of the cutaneous surface, the urine 
is almost constantly scant, and there has been a steadily increased thick- 
ening of the membrane lining the abdominal walls and of the parts 
constituting the mesentery, as readily determined by examinations 
each time after the withdrawal of the fluid. And yet the patient is 
now in sufficient health to render it probable that she will yet require 
several more tappings before reaching a fatal degree of exhaustion. In 
onl} r one instance was fluid withdrawn tinged with blood, and that was 
occasioned by the patient's having a fall, which caused a severe contusion 
of the distended abdomen about two weeks before tapping. It would 
seem in this case that the patient had been attacked primarily with a 
moderate chronic peritoneal inflammation, more particularly of that part 
of it which enters into the formation of the mesentery and meso-colon 
which has resulted in thickening and hypertrophy of the membrane, and 
a persistent exudation of serum. But in no part of her long stay in the 
hospital has she exhibited any marked febrile symptoms or any other in- 
dications of disease of an inflammatory character. 

Treatment. — Having mentioned the chief diagnostic symptoms of the 
different stages and varieties of chronic peritonitis, I shall pass directly to 
the treatment. This, in almost all the cases, must be palliative. When 
the disease has originated without connection with any general constitu- 
tional diathesis or local developments of a tuberculous or cancerous nature, 
benefit may often be derived from the internal administration of diuretics 
in connection with iodine alterants; more especially a combination 
of iodide of potassium with digitalis. If the patient suffers pain 
or much soreness, conium or hyoscyamus or belladonna may be added 
to the iodide and digitalis; and long continued moderate counter-irritation 
may be kept up over the surface of the abdomen. Occasionally in these 
cases temporary exacerbations indicating increase of local inflammation 
in some particular portions of the abdomen will occur, and I have seen 
the application of a blister under such circumstances productive apparently 
of decided good effects. But more generally instead of blistering, which 
to be effectual must be repeated, thereby incurring the risk of having the 
cantharides irritate the neck of the bladder, it is better to rely upon such 
applications as will produce decided stimulation of the surface without 
actually vesicating. A liniment composed of two or three parts of cam- 
phorated soap liniment, and one of the tincture of iodine may be used, by 
applying it over the whole abdominal surface morning and evening. 
When the inflammation is more circumscribed or limited to some particular 
part of the abdomen, and is not complicated with any constitutional dia- 
thesis, advantage may be derived from the use for a limited time, before 
the application of soap and iodine liniment, of a mercurial preparation, 
particularly of the oleate of mercury. But this must be used with suffi- 
cient caution not to allow the amount absorbed to produce constitutional 
effects or soreness of the mouth. It will be more advantageous to use it 
only for a few days first, and then follow it with iodine diluted with 
camohorated soap liniment. By thus using diuretics, mild alterants and 
anodynes internally with counter-irritation of a moderate character exter- 
nally, and persisting in their use for a considerable length of time, the 
progress of some cases may be arrested, the effusion that had taken 
place reabsorbed, and recovery produced. Where this does not result, 
the same treatment will retard the progress and alleviate the symptoms 



HEPATITIS. 589 

of the patient, and perhaps postpone the time when further measures must 
be adopted to relieve the abdominal distension. When, however, the 
latter occurs to such an extent as to seriously embarrass other functions, 
and is not readily reduced by such measures as I have indicated, instead 
of resorting, as is sometimes done to hydragogue cathartics, and thereby 
impairing the digestive organs, and yet getting only a temporary and 
moderate degree of relief from the serous accumulation in the abdomen, 
it is better to proceed to aspirate where the fluid is found to be only serous, 
and repeat the aspiration just as often as the abdomen becomes sufficiently 
distended to crowd upon the diaphragm. It is not well to repeat itoftener; 
indeed the aspirations or tappings should not be made as long as the 
patient can be comfortable, or can maintain the respiratory function with- 
out serious embarrassment, because every removal of two, three, or four 
gallons of serous fluid allows the exudation to proceed more rapidly, and 
in consequence more rapidly exhausts the blood of its albumen as well as 
saline and watery elements, and correspondingly reduces the patient. 
. When by aspiration it is found that the fluid in the abdominal cavity 
is pus, there is little hope, even of obtaining much temporary relief, or 
materially retarding the progress of the case. And the question whether 
the patient shall be rendered as comfortable as possible by palliatives, and 
the disease allowed to progress without any operative procedure, or 
whether the pus shall be removed by tapping with a large trochar, to 
which a Davidson's syringe is attached, and the abdominal cavity washed 
out cautiously, with artiseptic washes, and have drainage established as 
in cases of suppurative pleuritis, should be fairly considered by the prac- 
titioner, and his decision should rest much upon the disposition of the pa- 
tient, coupled with the degree of actual impairment of respiration and 
discomfort arising therefrom. Many of the patients become extremely 
anxious when suffering from dyspnoea, inability to lie down, and are worn 
out bjr the limited amount of rest they get, and should be afforded some 
relief, even if it be of a very temporary character. Under such circum- 
stances the withdrawal of the pus by either of the methods I have indi- 
cated would be justifiable and proper. I have purposely in this lecture 
said nothing in regard to the diagnosis, or differentiation, of ascites de- 
pendent upon the different forms of peritoneal inflammation, from the ova- 
rian cysts and other abdominal tumors, for the reason that the symptoms 
and measures relied upon for such diagnosis are given in more detail, and 
can be better appreciated when discussing the diseases from which the 
peritoneal inflammation is to be distinguished, than before such diseases 
have been brought under review. 



LECTUEE LVI. 



Hepatitis— Its Varieties, Clinical History, Anatomical Changes, Diagnosis, Prognosis and Treat- 
ment. 

GENTLEMEN: True inflammatory affections of the liver are less fre- 
quent in temperate and cold climates than the same forms of disease 
affecting different portions of the alimentary canal. In warm climates 
the liver is much more frequently involved in inflammation. When 



590 HEPATITIS. 

affected, the inflammation maybe limited to the parenchyma and secreting 
cells mainly, or it may be restricted more to the connective tissue, espe- 
cially that part of the connective tissue belonging to the capsule of Glis- 
son, and its ramifications through the organ. The whole organ may be 
invaded, or the disease may be iimited to particular portions of it — as to 
the convex surface, or to the right or left lobes separately. The inflam- 
mation may vary in its grade of activity from the most violent and rapidly 
progressive to the slightest and most chronic form of inflammatory action. 
For convenience, we shall consider the inflammations under the general 
divisions of acute and chronic. In giving the clinical history I shall con- 
sider the acute cases under the heads of, simple parenchymatous inflam- 
mation, circumscribed suppurative inflammation, and acute yellow 
atrophy. The chronic forms of inflammation I will consider under the 
names of chronic parenchymatous inflammation, which is most generally 
the sequel of acute attacks, and chronic interstitial inflammation more 
frequently originating, without being preceded by acute disease, and 
leading to such changes as are generally designated under the head of scle- 
rosis or cirrhosis. 

Simple Parenchymatous Hepatitis. — As I have stated, most of the 
cases that have been met with in practice, and described by writers, of 
this form of inflammation, occur in hot climates. Occasionally they are 
met with in all climates, and especially during the warm seasons of the 
year in malarious districts. Very rarely instances occur as the result of 
sudden exposure to cold and wet, during warm seasons of the year, 
where no malarious influences exist. 

Symptoms. — The symptoms which characterize an attack of simple par- 
enchymatous hepatitis vary much with the severity of the attack. In cases 
of moderate severity, the disease supervenes suddenly, with some degree 
of chilliness, which is of brief duration, however, and accompanied by a 
sense of heaviness and pain in the right hypochondriac region. The char- 
acter of the pain will vary according to the part of the liver most involved. 
If the disease is confined strictly to the parenchyma of the organ, the pain 
will usually be of a steady, dull, heavy character, generally increased by 
taking a full inspiration, or by any motion by which the diaphragm is de- 
pressed, and the side put upon the stretch. It is also accompanied by 
more or less direct tenderness both to pressure over the region affected, 
and particularly to percussion. The pain is also usually increased by 
turning upon the left side in the recumbent position, associated with a 
sense of dragging, or weight, and oftentimes also by a sense of nausea, 
and inclination to vomit. If the inflammation extends to the convex sur- 
face of the liver, involving the peritoneal covering, the pain will be much 
more acute, often resembling the sharp, lancinating pains of pleurisy, 
and aggravated in the same manner by tiie respiratory movements. In 
such cases also the pain sometimes extends backward under the right 
scapula and upward to the shoulder. The breathing is usually shorter, 
being stifled to avoid the sharp pains. The pulse is frequent, moderately 
full and firm under the finger, the skin dry, the face moderately flushed, 
the temperature of the body increased two or three degrees above the 
natural standard. Generally there is a thin whitish coat upon the tongue, 
more or less dryness of the mouth, frequently a heavy, dull pain through 
the forehead and temples, accompanied by dizziness upon taking the up- 
right position; and after the first two days very generally some degree of 
yellowness of the conjunctiva of the eye; a deep brownish red color of the 
urine, which is less in quantity than natural, and in most instances a 
moderate constipation of the bowels. 



SYMPTOMS. 591 

If the right hypochondrium is examined by auscultation and percussion, 
the firsr will d .'velop respiratory sounds throughout the whole depth of 
the chest above the diaphragm as usual, while the latter will indicate an 
increased area of dullness over the space occupied by the liver, associated 
directly with decided tenderness to the blows inflicted in the act of per- 
cussion. In most cases the enlargement of the liver will be such that its 
edge may be felt below the margin of the ribs, toward the right, and often 
it will extend further than usual into the epigastric region to the left. In 
most acute cases there is much disturbance of the functions of the stomach 
indicated by loss of appetite, frequent nausea and sometimes vomiting, 
especially when drink is taken in considerable quantities. The matter 
vomited at first may be freely intermixed with the coloring matter of bile, 
but at a later period is generally only the secretion of the stomach and 
the materials that have been taken as ingesta. In such cases as are 
occasionally met with in connection with attacks of malarious fever, and 
as I have seen, the result of direct exposure to wet and cold, the symp- 
toms I have described have usually increased moderately in severity, 
(luring the first three or four days. But if modified by appropriate treat- 
ment, they usually pass their climax, with the close of the third 
day and begin to abate. The pain diminishes, the general febrile symp- 
toms also diminish gradually, the tongue becomes more clean, the sense 
of fullness and weight in the right hypochondrium lessens from day to day, 
till at the end of from seven to ten days, convalescence has been estab- 
lished, and all the spmptoms, both of enlargement of the liver, and of 
functional disturbance have ceased. In a few instances, where the treat- 
ment had been neglected during the early stage, the disease has run a 
more protracted course; causing a much greater degree of enlargement 
of the liver, more general prostration of the patient, the pulse at the end 
of a week ranging from 110 to 120 beats per minute, being smaller and more 
easily compressed. The skin and eyes become deeply yellow, the coat- 
ing upon the tongue more brown and dry in the middle; the bowels more 
or less constipated, the urinary secretion decidedly scanty and very deeply 
tinged with the coloring matter of bile. In two or three cases, such as I 
have now referred to, the acute stage of the disease gradually declined, with 
an amelioration of the more active symptoms, such as fever, pain in the side, 
and quick pulse, and yet the liver remained much enlarged, jutting from 
one to two inches below the margin of the ribs, through the whole extent 
of the hypochondriac region; it was moderately tender to percussion, and 
there was a continuance of the sense of weight, heaviness and more or less 
pain, on taking deep inspirations, or on any free motion of the affected 
side. These were cases in which the acute form of disease terminated in 
the establishment of a well marked chronic inflammation, accompanied by 
enlargement and induration of the substance of the liver. In three of the 
cases coming under my own observation, the hepatic enlargement and 
induration continued from two to three months, subsiding very slowly, 
but ending in the ultimate recovery of the patient. In the fourth case, 
after having continued in the chronic form, with much enlargement of 
the liver for nearly three months, suppuration took place, indicated by 
the occurrence of irregular chills, copious sweats, increased rapidity of 
pulse and emaciation, and a well marked increased swelling in the right 
portion of the hypochondriac region corresponding with the convex por- 
tion of the right lobe of the liver. In this case a large abscess approached 
the surface near,enough to give distinct fluctuation between the eighth and 
ninth ribs a little forward of their angles. Although the abscess was 
opened and discharged its contents, leading to a temporary improvement 



592 HEPATITIS. 

of the patient, the subsequent occurrence of hectic symptoms and pro* 
gressive emaciation terminated the case fatally at the end of six months 
In hot climates, acute parenchymatous inflammation gives rise to the 
occurrence of the same class of symptoms as I have described, but they are 
usually mere violent; the fever is of a higher character, often accompanied 
by delirium, there is a very much more 1 scanty condition of urine, and 
earlier jaundice or a yellow hue of skin and eyes; frequently severe vomit- 
ing, rapid enlargement of the liver, which occupies and bulges the hypo- 
chondriac space, crowding upon the parts below and in the epigastrium, 
and not infrequently terminating fatally in from five to seven days. It 
is in such climates, and in this acute form of the disease, that it manifests 
a more decided tendency to suppuration, and the formation of one or 
more abcesses, if the patient survives beyond the first week from the be- 
ginning of the attack. The supervention of suppuration in the acute 
form of the disease is usually indicated by the development of chills, 
followed by profuse sweats, a more rapid pulse and more rapid emacia- 
tion, loss of strength; and often also by the almost entire suppression of 
urine, accompanied by delirium and coma, a little preceding the fatal 
termination. 

The form of the disease, which has been termed acute yellow atrophy of 
the liver, I have classed among the acute inflammations, though well aware 
that many writers doubt its inflammatory character. It is of very rare 
occurrence in temperate and cold climates. It is not of frequent occur- 
rence in any climate, but cases occur much more frequently within the 
tropics and in the warmer latitudes than elsewhere. Its symptoms are 
usually developed rapidly, though oftentimes in a manner to render the 
diagnosis extremely obscure. The patients are generally seized with 
more or less chilliness, speedily followed by an increase of heat and rapid 
pulse, though this oftentimes varies much in the same patient, being some- 
times 120 to 130 in the minute, at others falling as low as 70 or 80. The res- 
piratory movements are hurried and irregular. There are severe pains in 
the head, with frequent turns of delirium, or high excitement and occasion- 
ally severe vomiting. The bowels at times are costive and at other times 
loose, but there is seldom any evidence of the coloring matter of bile either 
in the matters ejected by vomiting or passed through the bowels. The urine 
from the beginning is very scanty and high colored, containing much less 
than the natural proportion of urea, and not infrequently an excess of both 
leucin and tyrosin. The skin and eyes also become deeply yellow, almost 
from the commencement of the disease. In the very violent cases, during the 
second and third days, petechial spots make their appearance in different 
parts of the cutaneous surface, and not infrequently hemorrhages either 
from the mouth and gums, or from the stomach by vomiting, and some- 
times blood passes the bowels, or is mixed with the urine. Most of these 
cases terminate fatally in from three to seven days. The symptoms refer- 
able to the right hypochondriac region are very variable. Generally in 
the commencement there is acute pain, a sense of heaviness in that region 
increased by motion of the diaphragm, but there is seldom any indica- 
tions of enlargement of the liver. While percussion will afford evidence 
of tenderness over the hypochondriac region, sometimes very acute, at 
other times very moderate, there is no increased area of dullness, but on 
the contrary, after the first two days, the liver appears to occupy less 
space than natural. This absence of any indications of enlargement of 
the liver, the variableness of the pain referable to that, region, coupled 
with the very early delirium, violent vomiting, great functional disturb- 
ance of the kidneys, would be likely to divert the attention of the practi- 



ANATOMICAL CHANGES. 593 

tioner from the liver as the seat of disease altogether, were it not for the 
coincident and early supervention of yellowness of the skin and eyes, 
and the presence of the coloring matter of bile in the urinary secretion. 

Anatomical Changes. — The anatomical changes which take place dur- 
ing the progress of acute inflammation in the liver are similar in kind 
to those which result from inflammatory processes in any other tissue of 
the body. There is in all cases intense injection of the blood vessels, 
thereby increasing the fullness of the organ and rendering the color more 
red, but as the cases of simple inflammation progress, exudation takes place 
into the interstitial spaces of the tissue, leucocytes or white corpuscles are 
found permeating the vessels or outside of the vessel wal's, and lymphoid 
and spindle shaped cells are found multiplying rapidly. There is also 
more or less obstruction of the smaller vessels in the inflamed parts. In 
acute cases, the surface of the liver is variable in color, some portions of it 
being deep red, others of a more decidedly yellow hue. In cases that 
have terminated fatally during the active stage of the disease, the texture 
of the liver is generally softer than natural. If suppuration has taken 
place, the pus will generally be found to have collected into one or more 
abscesses, instead of being diffused through the parenchyma of the organ. 
The walls of the abscesses will usually be denser and firmer from the in- 
crease of connective tissue. The changes which result in that variety of 
disease known as acute yellow atrophy, consist in a rapid disintegration 
and apparent disappearance of the secreting cells of the liver, causing 
a diminution in the number of them wherever the structure is ex- 
amined. In place of the secreting cells throughout the lobules of the 
liver, there is found by microscopic examination aggregations of dark bile 
pigments, fatty matter and masses of haematin. It is this rapid disappear- 
ance of the secreting structure, and its replacement with the constituents 
just mentioned, that apparently causes the rapid atrophy of the organ; it 
frequently being less than half its natural size, and of a more flattened 
form. Its color is also changed to a more decidedly yellow hue, more 
nearly that of the rhubarb root. The connective tissue maintains very 
nearly its natural integrity, and in some places appears to have increased 
by hypertrophy or sclerosis. Many of the branches of the portal veins 
are obstructed or obliterated, while those of the hepatic artery are found 
dilated and enlarged, and those of the hepatic veins nearly natural. These 
anatomical changes have caused some pathologists to regard the disease 
as not inflammatory in its character, but acute fatty degeneration of the 
organ, resulting either from some morbid condition of the blood or from 
the direct infection by bacterial germs. In nearly all the cases that have 
been examined of this form of disease, the kidneys have been found coin- 
cidently to have undergone much degeneration of structure causing an al- 
most entire suspension of their secretory function. The blood itself has been 
found to contain a large proportion of cholestrine an d of the coloring material 
of the bile, and in some instances also an excess of urea. This would lead 
to the suspicion that the functions both of the liver and kidneys are early 
suspended, allowing the fatty constituents of the bile to rapidly accumulate 
in the blood. And it is undoubtedly this rapid accumulation of the ex- 
cretory elements operating as poisons upon the nervous centers, that 
produces most of the prominent symptoms and phenomena of the disease 
during its whole progress, and which leads in almost all instances to an 
early fatal result. 

Diagnosis. — Acute hepatitis, whether mild or severe, is generally ac- 
companied by symptoms so well marked as to leave no difficulty in form- 
ing an accurate diagnosis. The chief diseases with which acute hepatitis 
38 



594 HEPATITIS. 

may be confounded are — acute pleuritic inflammation in the right side of 
the chest, acute rheumatism located in the diaphragm and lower inter- 
costal muscles, and neuralgic pains in the sam'3 parts. When inflamma- 
tion affects the convex surface of the liver, the general symptoms, so far 
as they relate to acuteness of pain, interference with respiration, 
increased frequency of pulse and general fever, are closely analogous 
to pleuritis; but are easily differentiated by physical examination. In the 
pleuritic affection, auscultation in the first stage readily reveals friction 
sound, and in the second stage with disappearance of the friction sound, 
we have dullness on percussion, with a removal of the ordinary respira- 
tory murmurs over the lower part of that side of the chest. While in 
hepatitis of any grade or degree of severity the respiratory sounds con- 
tinue natural throughout the whole depth of the chest, yielding neither 
friction in the beginning, nor absence of respiratory murmur with dull- 
ness on percussion at any subsequent stage. But while auscultation and 
percussion thus furnish no evidence of change in the chest above the dia- 
phragm, in hepatitis the percussion below the diaphragm shows both 
acute tenderness and increase of dullness, extending downward and to 
the left, thereby clearly showing that the disease is below the dia- 
phragm, and involves an enlargement of the liver instead of any changes 
in the chest, as would be the case in either pleurisy or pneumonia. I 
have seen many cases of subacute rheumatism, affecting the diaphragm 
and intercostal muscles that have been mistaken for hepatitis. As the 
pain of rheumatism is dull and continuous, very much like that affecting 
the parenchyma and deeper portions of the liver, and may give rise to the 
same tenderness on percussion over the part, there is necessity for care- 
ful examination to prevent mistakes in such cases. In the rheumatic af- 
fections you get no friction or alteration of sound by percussion or auscul- 
tation above the diaphragm. But there is this clear line of distinction 
between the rheumatic affection and hepatitis. The former is never ac- 
companied by any increased area of dullness in the right hypochon- 
driac region, neither is it accompanied by the peculiarly dark hued urine 
occasioned by the intermixture of the coloring matter of bile, nor by yel- 
lowness of the skin or eyes; while hepatitis, especially of an acute char- 
acter, is accompanied from a very early period after the symptoms com- 
mence by not only an increased area of dullness on percussion and by such 
enlargement as enables the margin of the liver to be felt below the ribs, 
causing heaviness and dragging sensations on turning to either side, but 
also very uniformly by a characteristic alteration in the color of the urine as 
well as of the skin and conjunctiva of the eye. From all forms of neuralgia 
acute hepatitis is distinguished by the presence of tenderness, fullness of 
the hypochondriac space and more or less general febrile movements, as 
well as alterations in the color of the skin, eyes and urine, all of which 
symptoms are absent in the neuralgic affections. In addition to the diag- 
nosis of hepatitis from other affections, it is often important to note such 
diagnostic symptoms as indicate the commencement of suppuration. These, 
as I have already mentioned when speaking of the clinical progress of 
the disease, are usually the sudden occurrence of a chill, followed almost 
invariably by sweating, and a decided increase in the frequency of the 
pulse, with diminution of its volume and force. The recurrence of chills 
and sweats at irregular intervals, with increased rapidity of emaciation 
and increased frequency and diminished force of the pulse, accompanied 
by evidences of more rapid enlargement in some one direction in the 
hypochondriac region, will justify the conclusion that suppuration has 
taken place. The diagnostic symptoms of acute yellow atrophy of the 



PROGNOSIS. 595 

liver are the coincident and rapid development of yellowness of the skin 
and eyes, and marked diminution of the urinary secretion and its change 
to a brownish yellow color from intermixture of bile pigments and de- 
ficiency of urea, with violent disturbances of the cerebral functions, rapid 
deterioration of the blood, as indicated by extreme depression, with ten- 
dency to hemorrhages, either in the form of patechial spots upon the sur- 
face or haemorrhages from the mucous membrane, associated with vomiting 
and diarrhoea, without any coincident enlargement of the hypochondriac 
region, but rather with rapid diminution in the area of dullness. 

Prognosis. — The prognosis in ordinal simple acute inflammation of the 
liver in temperate climates is generally favorable. In warm climates the 
prognosis is more grave, the disease having much more tendency to de- 
velop rapid structural changes, either in the direction of softening, acute 
fatty degeneration or suppuration, and consequently a much larger 
number terminate fatally. The special form known as acute yellow atro- 
phy is extremely dangerous, terminating fatally in almost all the cases in 
which the diagnosis has been made with any degree of certainty. This 
form of disease is of such rare occurrence in this climate that I have no rec- 
ollection of meeting with more than two cases that could be justly placed 
under this head. Both of these were visited in consultation with other 
physicians, and were in the advanced stage of the disease. One of them 
vomited blood copiously, and both terminated fatally within the first five 
days after the commencement of the attack. Both of these cases wer<^ 
females; and it would appear from statistics which have been gathered 
that females are more subject to this form of the disease than males, and 
that it is more liable to occur during the state of pregnancy than during 
any other time. Much the larger number of cases have occurred between 
the ages of fifteen and thirty years. 

Treatment. — In mild cases of acute inflammation of the liver, such as 
are occasionally met with in connection with sudden exposure to cold and 
damp, and with attacks of malarious fevers, it is generally sufficient to 
confine patients to rest in the recumbent position, administer some mild 
evacuants, and the pain and soreness rapidly disappear. Perhaps the 
best evacuants for this purpose, consist of from two to three decigrams 
(gr. iii to v) of calomel, followed in about three hours by a saline laxative 
sufficient to procure a free movement of the bowels. If the case is con- 
nected with malarious influence there may be given directly with the 
mercurial, three decigrams (gr. v) of quinine, and after the bowels have 
been moved freely, the quinine may be continued in the same doses, 
three times a day for three or four subsequent days. If the sense of full- 
ness and tenderness in the hypochondriac region proves to be persistent, 
a blister may be placed on that side, and internally the patient may be 
given from four to six decigrams (gr. vi to x) of the muriate of am- 
monium three times a day in solution with syrup of licorice. In the 
more severe cases, such as are met with frequently in warm climates, 
if the attack has sup3rvened suddenly, and the patient has not been 
previously debilitated by ill health or age, it will often be advantageous to 
commence the treatment immediately after the onset of the inflammation 
by one free venesection. If the relief is not satisfactory, the bleeding 
may be followed in eighteen or twenty-four hours, by the application of 
eight or ten leeches over the hypochondriac region; and both before and 
after the application of leeches during the first two days, the whole side 
may be kept covered with narcotic fomentations. Internally, immediately 
following the bleeding, where this is deemed advisable, it is better to give 
the patient a powder, consisting of six decigrams (gr. x) of bi-carbonate 



596 HEPATITIS. 

of sodium and six centigrams (gr. i) of the mild chloride of mercury every 
three hours, until three or four of these doses have been taken. If they 
do not result in a direct operation upon the bowels, they should be fol- 
lowed by sufficient rochelle salts, or citrate of magnesium to procure a 
free operation. Following the free movement of the bowels, the patient 
may be put directly upon the use of the muriate of ammonium, in the same 
doses I have previously mentioned, but instead of three times a day, it 
should be given once in three or four hours; and if the patient continues to 
suffer from much acute pain or a sense of soreness, there may be added suf- 
ficient morphine to the solution of muriate of ammonium, to give it a 
moderately anodyne influence. If the skin is hot and dry it will also add 
to the efficiency of the treatment if the tartrate of antimonium and potas- 
sium is added to the same solution in such proportion that the patient 
will get from fifteen to twenty milligrams (gr. \ to -J) in each dose. In 
acute inflammatory affections of the liver, where it is not complicated 
with irritation of the gastric mucous membrane, I have derived the most 
satisfactory results from the use of a combination of muriate of ammonium, 
tartrate of antimonium and potassium, with sulphate of morphia, dissolved 
in syrup of licorice, commenced immediately after the first free opening 
of the bowels, in the early stage of the disease. In some cases under 
treatment, the general fever diminishes, the acute pain disappears, but 
there remains a sense of fullness, weight and tenderness, with evident en- 
largement of the area of dullness over the hepatic region, thereby showing 
a disposition to persist and perhaps to assume a chronic form. Counter- 
irritation by blistering will be of much value at that stage, with con- 
tinuance of such doses of the muriate of ammonium as the stomach will 
best tolerate. But in those very rapid and severe attacks, where after 
the first two or three days chilliness supervenes, and the phenomena in- 
dicate the existence of suppuration, no treatment usually produces much 
modification in the symptoms until suppuration has advanced sufficiently 
to allow of either an artificial or spontaneous discharge of the matter. As the 
tendency to spontaneous discharge is usually either directly into the peri- 
toneum, or through adhesions into the colon, or sometimes into the stomach, 
or at other times upward through the diaphragm into the lungs, or through 
the walls of the abdomen to the exterior, all of which involve a slow, 
tedious process, and more or less ultimate danger to the patient's life, it 
is very desirable to prevent such spontaneous discharges of the pus by 
an early resort to aspiration, and if need be to a sufficiently free opening 
to admit of a complete drainage of the abscess. The greater number of 
cases of suppuration in the liver progress forward and downward as if 
tending to approach the surface just upon the lower right margin of the 
epigastric region. The next most frequent tendency is in the direction 
of the posterior part of the hypochondriac space usually between the 
eighth and ninth ribs. Whenever the results of physical exploration by 
palpation and percussion, corroborated by the general symptoms of the 
patient, are sufficiently characteristic to justify a confident opinion that 
an abscess has formed, you may feel justified in making an exploratory 
puncture with the aspirator needle, thereby demonstrating whether pus 
exists, and can be reached or not. It has been reoommended by very 
high authority that in such ^ases, a free incision be made over the 
most prominent part of the swelling, through the textures, down to with- 
in a few lines of the peritoneum, not puncturing the peritoneum nor 
puncturing the abscess, but carrying the incision two or three inches in 
length down close to the peritoneum, filling it with cotton, and leaving 
it for two or three days, during which more or less suppuration takes 



CHRONIC HEPATITIS. 597 

place accompanied by adhesive inflammation in the adjacent textures, 
thus making sure of the adhesion of the peritoneum to the surface of the 
liver, and in most ins.ances of a rapid advance of the abscess to spontane- 
ous discharge from the bottom of the incision. 

In cases where matter is found, and it is too thick, as sometimes 
happens, to flow freely through the ordinary asp rator tube, it can be much 
more freely and completely evacuated by using a small trochar fitted to 
a Davidson's syringe in place of the aspirator needle. If the abscess re- 
fills, after it has been aspirated two or three times, and consequently you 
have reason to suppose that there are certainly adhesions between the peri- 
toneal surfaces, leaving no danger of matter passing into the abdominal 
cavity, the opening can be enlarged sufficiently to give free exit to the mat- 
ter, and drainage can be established with ordinary antiseptic precautions. 
Abscesses in the liver, whether resulting from acute or chronic inflam- 
mation always involve more or less danger; yet where they can be evacu- 
ated judiciously in the manner I have indicated, the larger proportion of 
them will recover. Of six cases that have fallen under my own care, as 
I now remember, four recovered, two were relieved, and continued for 
several months, but ultimately died from exhaustion in consequence of 
continued suppurat on. 

Chronic Hepatitis. — Chronic inflammation of the liver is met with in prac- 
tice under two forms. The first is the sequel of more acute, general attacks 
of hepatitis, and is characterized by the physical signs of enlargement of 
the liver, such as increased area of dullness on percussion, ability to trace 
the edge of the liver below the margin of the ribs, a constant feeling of 
weight, increased to a dragging sensation when the patient turns on the 
opposite side, very generally a dull pain in the hypochondriac region which 
not infrequently extends to the back under the scapula, sometimes to the 
shoulder, an acceleration of pulse, a slight febrile movement in the after- 
noon and evening, a gradual loss of flesh and strength, and most generally 
a loss of appetite and some degree of derangement in the digestion of what 
food is taken. In a majority of instances the skin and eyes are more or 
less tinged a yellow color; sometimes deeply so, at other times only slightly. 
After the disease has continued some few weeks, dropsical symptoms 
very generally supervene; sometimes a slightly cedematous condition of the 
tops of the feet, about the malleoli of the ankles when the patient is sitting 
up, will be observed for several days before any other noticeable, dropsical 
feature; but more generally no symptoms of oedema are seen in the areolar 
tissue, either of the face or extremities. Very generally, however, the 
patient finds in addition to the ordinary fullness of the right hypochondriac 
region that the lower part of the abdomen also begins to be more prom- 
inent and heavy than natural. At the same time the urinary secretion is 
more scanty, and also tinged with the coloring matter of bile. The full- 
ness in the lower part of the abdomen is not usually accompanied by 
pain or any ill feeling other than that of weight, and it increases slowly 
from day to day, till at the end of from five to six weeks there will be 
considerable distensio.i of the peritoneal cavity, and in proportion as this 
distension increases the patient suffers much from a sense of heaviness 
and oppression whenever he takes food, and sometimes is provoked to 
reject it by vomiting. If the abdomen is examined at any time there 
will be no difficulty in detecting distinct fluctuation of fluid. The fluctu- 
ation becomes more and more distinct as the accumulation increases. If no 
measures are taken for the relief of the patient, he will arrive at a stage 
of distension from the accumulation of serous fluid in the cavity of the 
peritoneum, such as to compress the stomach, thus preventing the reception 



598 CHRONIC HEPATITIS. 

and digestion of food; to crowd the diaphragm upward sufficiently to 
very much impede the process of respiration, thereby causing biueness of 
the lips, coldness of the extremities, extreme feebleness of the pulse, 
drowsiness and yet inability to sleep. And if not interfered with, the 
mind becomes incoherent, the urine nearly suppressed, and finally coma 
and death supervene. 

Thus far I have spoken simply of chronic hepatitis, as it is occasion- 
ally met with, resulting from prior acute or subacute attacks. We occa- 
sionally meet with cases in practice in which the liver is attacked with 
chronic inflammation, very circumscribed in extent and almost always 
secondary to or as a complication of other affections. Chronic dysentery 
especially, is every now and then complicated with circumscribed in- 
flamma ion of the liver, accompanied by very obscure symptoms, until 
suppuration has supervened, when there develops in a few weeks, all the 
phenomena of a hepatic abscess. Similar results take place sometimes 
during the progress of chronic inflammation in any part of the alimentary 
canal. And they are occasionally met with during convalescence from 
general fevers, especially those of a typhoid and typhus character. Another 
form of chronic hepatitis, which is more common than those to which I 
have already alluded, is properly styled interstitial inflammation. It oc- 
curs almost exclusively in adults or persons between the ages of fifteen 
and fifty years who are addicted more or less to the use of alcoholic 
drinks. Some eminent writers claim that it occurs only from the use of 
whisky, gin, brandy or the more concentrated alcoholic beverages. I 
am not satisfied, however, that it is limited exclusively to those who use 
such drinks. I think I have seen a few very well marked cases of this 
form of disease, in patients who had certainly not used any form of alco- 
holic drink. Such cases are exceedingly rare, however, while thev are very 
common in those who have habitually used this class of beverages. The 
disease to which I am now alluding is more generally termed cirrhosis of 
the liver. It is much more proper, however, to designate it sclerosis, 
becau-e cirrhosis has reference to yellow color and the patients are by 
no means always jaundiced or yellow. Neither is the liver itself always 
of a yellow hue, consequently, the name cirrhosis is not strictly applica- 
ble to all cases; while sclerosis, which relates directly to the patholog- 
ical changes in the connective tissue of the liver, has reference to a con- 
stant element in the pathology of the disease. The symptoms which 
characterize the commencement of this form of hepatitis are obscure, and 
very often either escape altogether the attention of the practitioner, or 
are misinterpreted, till the disease has so far progressed as to cause the 
beginning of dropsical effusion. Whenever an opportunity has been 
afforded to study the clinical history of this class of cases, I have found, 
among the earliest symptoms, obscure pain extending from the center of 
the epigastrium to the right, through nearly the whole right hypochon- 
drium; better described as a dull, heavy sensation than anything like 
acute pain. Percussion, however, over any part of the hypochondriac 
region, and into the right margin of the epigastric, pretty uniformly caused 
increase of soreness, and sometimes the sensation of nausea. The sore- 
ness was also increased by any kind of motion which put the side on the 
stretch. The tongue was covered with a yellow thin coat, especially over 
the middle and back part. There was loss of appetite, slight acceleration 
of pulse, very little increase of temperature. In some cases there was 
also frontal pain, moderate constipation of the bowels, high-colored and 
scanty urine, and occasionally, slight yellowness of the conjunctiva, but sel- 
dom any general jaundice or noticeable yellowness of the whole surface. 



ANATOMICAL CHANGES. 599 

If food was taken, even in small quantities, there was pretty uniformly de- 
fective digestion accompanied by eructations of gases and sometimes acids. 
These symptoms usually continued for about one week, when under mild 
treatment they were relieved. Nearly all the symptoms disappear during 
the second week, and the patients claim to be very well except a lack of 
the usual strength or power of endurance and the continuance of some 
obscure defect in the digestion of food. 

In most cases, these symptoms will be so slight that the patient thinks 
he requires no further medical attendance. But at the end of three or 
four weeks he finds himself weaker, tiring easily, with a little increase of 
indigestion, gaseous eructations after taking food, with unusual fullness 
of the abdomen. The latter continuing to increase, he again calls upon 
his physician, who on examination finds him pale from deficiency of red 
corpuscles in the blood, with a soft, easily compressible pulse which is a little 
increased in frequency, but with no general fever. Sometimes the con- 
junctiva shows a tinge of yellow, but the most prominent feature of the 
case is considerable enlargement of the abdomen. On examination by 
palpation and percussion, this enlargement is found to consist of an ac- 
cumulation of fluid in the cavity of the peritoneum. Occasionally, if 
examination is made very closely, at this stage, in addition to the disten- 
sion of the peritoneal cavity with serous effusion, traces of moderate en- 
largement of the liver may still be found. In many instances, however, 
no trace of enlargement can be found; but on the contrary the line of 
intestinal resonance produced by the transverse colon will be found fairly 
above the margin of the ribs, showing that the liver has receded by a 
lessening of its size rather than otherwise. From this time the symp- 
toms in these cases are pretty uniform. The abdomen becomes more and 
more distended with serous fluid, the patient becomes more pale, anasmic, 
less able to be on his feet and get about, and from the mechanical pres- 
sure in the peritoneal cavity backwards upon the renal vessels, upward 
against the diaphragm and stomach, respiration, digestion and the renal 
secretion are all more or less interfered with. Consequently the patient 
loses strength pretty rapidly, and in a few weeks is reduced to the alter- 
native of having the fluid removed from the cavity of the abdomen by 
some means, or of suffering fatal interference with the respiratory and 
digestive functions, or as occasionally happens in such cases, from such a 
degree of suppression of the urine as to produce ursemic poisoning, con- 
vulsions, coma and death. 

Anatomical Changes. — The anatomical changes which take place in 
the progress of this variety of chronic hepatitis, are the result of a slow 
inflammatory process, apparently established primarily in the connective 
tissue, constituting the capsule of Grlisson and its ramifications through 
the structure of the liver surrounding individual lobules and secreting 
cells. The morbid excitability, and increased vascularity of this tissue 
constituting the inflammation, causes an increase of cell proliferation 
making the lymphoid and spindle cells very abundant, and by their ac- 
cumulation, sclerosis or hypertrophy of the connective tissue takes place, 
and by pressure directly on the thin walls of the branches of the portal 
vein, obstructing and even obliterating a large proportion of the smaller 
branches. At the same time, the hypertrophy of this tissue causes more 
or less atrophy of the secreting cells in the lobules, and in some instances 
their separation into rows, giving them, when examined under the micro- 
scope, much the appearance of biliary ducts studded with epithelium. 
The biliary ducts, however, and the ramifications of the hepatic arteries 
are not as much obstructed as the branches of the vena porta. The hy- 



600 CHRONIC HEPATITIS. 

pertrophy of the connective tissue with atrophy of the secreting lobules 
results in a general contraction of the liver. The diminution of size is 
very unequal, giving it a nodulated appearance with rounded prominences 
on its surface which has given rise to the name " hobnail liver." The 
coior is generally lighter or more yellow than natural. The size of the 
organ continues to diminish usually in proportion to the duration of the 
disease, until in some instances it is found less than one third the natural 
size. In a patient coming under my care, in whom the disease had existed 
for two years before reaching a fatal result, a post-mortem revealed the 
liver hardly larger or thicker than my hand. Post-mortem examinations 
also reveal in most instances, some traces of chronic inflammation in the 
mucous membrane of the stomach and duodenum, and in most cases the 
spleen is also found to have undergone some degree of chang i , similar in 
its character to that which has taken place in the liver; and probably 
from the action of the same causes. The dropsical effusion which occurs 
very constantly in connection with this disease is limited almost entirely 
to the cavity of the peritoneum and results directly from obstruction of 
the portal vessels. When the abdomen is allowed to become very largely 
distended with effused fluid, the pressure upon the ascending vena cava 
and common iliacs, in the lower parts of the abdomen will sometimes so 
far obstruct the return of blood as to induce much oedema of the lower 
extremities and scrotum, but as a direct result of the disease of the liver, 
the dropsical effusion is limited almost entirely to the cavity of the peri- 
toneum. I should remark, however, that the contraction of the liver as 
the result of sclerosis of the connective tissue has not invariably occurred. 
In some rare cases, the liver has continued to be its full size, or even 
larger than natural throughout the whole course of the disease. In such 
cases there is the same change in the connective tissue and more or less 
dropsical effusion, but the liver remains smooth upon its surface, although 
presenting a granular appearance. These cases have been regarded by 
some as a separate and distinct form of disease from that of sclerosis of 
the liver. Though arising evidently from the same causes, in the same 
class of patients, leading to similar results, and the anatomical changes 
which take place in the structure the same in all respects except the 
failure of the secreting lobules to undergo atrophy, and consequently 
there occurs no progressive diminution of the size of the organ. 

Diagnosis. — There are no symptoms that can be said to be absolutely 
diagnostic of this form of disease in its early stage. Wherever in a 
patient accustomed to the habitual use of alcoholic drinks there is found 
distinct tenderness on percussion over the hepatic region, in addition to 
the other symptoms that I have before described, it is safe to assume that 
there is at least danger of developing this form of disease. The only 
absolute diagnosis, however, is based upon the physical signs of contrac- 
tion of the liver, or its occupying less space than natural, coincident with 
evidences of commencing effusion in the cavity of the peritoneum. 

Prognosis. — The prognosis in all cases of well established chronic in- 
flammation of the liver, whether as the result of prior general acute at- 
tacks, or whether it be primarily chronic, of the interstitial form such as 
I have just been describing, is not favorable. There is much danger that 
the disease will persist until it shortens the life of the patient. Yet those 
cases which are the sequel of acute attacks, or arise from any cause not con- 
nected with sclerosis, if they have not been allowed to progress too far, 
and can be brought under judicious treatment, a reasonable expectation 
may be entertained of their ultimate recovery. So, too, if the interstitial 
form of the disease is actually diagnosticated early before the liver 



TREATMENT. 601 

has undergone marked changes in its structure, or before any dropsical 
effusions have occurred, there is also a reasonable chance of conducting 
the patient to a permanent recovery. But in all instances where changes 
have taken place to such an extent as to interfere with the portal circula- 
tion and induce the beginning of dropsical accumulation within the peri- 
toneum, permanent recovery is a very rare occurrence. The work of the 
physician in such cases is limited almost exclusively to the palliation of 
symptoms and prolongation of life, with little or no probability of promot- 
ing a cure. 

Treatment. — But few words need be added in regard to the treatment 
of chronic hepatitis. Such cases as come under the observation of the 
physician before the structural chauges have gone sufficiently far to in- 
duce dropsical effusions, wiil be most efficiently treated by the use of 
mild saline laxatives to procure a moderately free movement of the 
bowels. If the urinary secretion is quite scanty, the patient may be at 
the same time put upon the use of an equal mixture of liquor ammonii 
acetatis and nitrous ether, in doses of four cubic centimeters (fl. 3') 
four times a day. If there be any quickness of pulse or slight fever, tinct- 
ure of digitalis may be added to this mixture in such proportions as to 
give ten or twelve minims to each dose of the other ingredient. After the 
bowels have been moved, I have derived more advantage from the use of 
the following- formula, in chronic inflammation with more or less indura- 
tion and swelling of the liver, than from any other remedy or remedies 
that I have used* 

^ Ammonii Muriatis 15.0 grams, |ss 

Hydrargyri Chloridi Corosivi .1 " gr. iss. 

Extracti Conii Fluidi 20.0 c.c. 3v 

Syrupi Glycyrrhizas 145.0 " §ivss 

Mix. Of this I have usually directed for adults four cubic centimeters 
(fl. 3') diluted with a little additional water, four times a day. Several cases 
were benefited by keeping up, during the first one or two weeks, a 
moderate degree of counter-irritation over the right hypochondriac region 
by the application of a mixture of croton oil, tincture of iodine and sul- 
phuric ether which was painted over a moderate extent of surface morning 
and evening with a camel's hair pencil. Usually, in two or three days 
a moderate vesicular eruption is produced over the surface to which the 
mixture has been applied; and then by lightly touching it once a day, 
or once every alternate day, it may be kept at such a degree of 
soreness as is desirable, for one or two weeks. In most cases that are 
curable the internal alterants that I have mentioned coincident with ex- 
ternal irritation has been sufficient to produce a slow but steady reduction 
of the inflammation and swelling until convalescence has been estab- 
lished. As the patient improves the number of doses in the day may be 
diminished; first, to three a day, subsequently to one morning and even- 
ins;, until recovery has so far advanced as to allow of its discontinuance. 
While this treatment is being pursued, due attention should be given to 
the condition of the stomach and bowels; the latter being moved at least 
every alternate day, if they are not disposed to keep regular without the 
use of laxatives. If the. kidneys need prompting, the same mixture that 
I have just mentioned as a diuretic will be sufficient for that purpose. 

The patient's diet should be very simple, unstimulating; better if it 
can be made to consist largely of farinaceous articles and milk; no alcoholic 



602 CHRONIC HEPATITIS. 

drinks of any kind, fermented or distilled, should be allowed in any of 
these cases. In the treatment of the first or early stage of interstitial hep- 
atitis, more commonly called cirrhosis, before any dropsical effusions have 
taken place, the exhibition of one or two grains of blue mass, followed by a 
saline laxative, and subsequently by two or three doses each day of a solu- 
tion of the muriate of ammonium, corrosive chloride of mercury and conium 
(see formula on preceding page), is a method of treatment which will be 
found perhaps more reliable and efficient than any other. To afford 
a chance of arresting them, however, it must be absolutely adopted early, 
before such changes have taken place as to cause any beginning of 
dropsical effusion. After such effusions have taken place I have never 
known treatment to result in anything further than a palliative influence. 
The great question for the practitioner after cirrhosis or sclerosis of the 
liver has advanced far enough to establish serous effusion into the cavitv 
of the peritoneum, is by what method will he be enabled to retard the 
accumulation of serum and sustain the functions of digestion and assimi- 
lation most efficiently? The common practice is to endeavor to keep down 
effusion by resorting to diuretics and hydragogue cathartics. The first 
or milder class of diuretics, so long as they can be made to influence the 
urinary secretion, without deranging the stomach or destroying digestion, 
will be of much benefit to the patient. Hydragogue cathartics have ever 
in my own hands appeared to do the patient more harm than good. To 
produce an impression in reducing the amount of dropsical accumulation, 
the patient must be physiced, at least from three to four times in twenty- 
four hours, and the evacuations must be copious and watery. Less than 
this will make no impression, and yet I have never found a patient who 
could be kept under the influence of podophyllin or any other hydrogogue 
cathartic of sufficient activity to procure any number of evacuations, 
without at the same time producing inflammation in the mucous 
membrane, more than enough to offset the benefits gained in lessening 
the amount of dropsical effusion. Consequently I am satisfied, from long 
and abundant experience, that the use of hydragogue cathartics in these 
cases is not beneficial, and can seldom be resorted to without ultimate 
detriment to the patient. It is a much better rule to keep down the 
dropsical accumulation as far as practicable by the milder class of diuret- 
ics, and when these fail so that the accumulation and consequent disten- 
sion begins seriously to inconvenience the respiration by crowding 
against the diaphragm, and equally to interrupt digestion by pressure 
upon the stomach, aspiration or direct tapping should be resorted to for 
the removal of the dropsical fluid, and followed by bandaging the abdomen, 
and by such diuretics as may be most beneficial, in increasing the renal 
secretion, and thereby retarding the dropsical reaccumulation. If the 
latter does occur, however, aspiration or tapping will again be much pref- 
erable to the depleting effects, or more properly the irritating effects of 
the hydragogue cathartics upon the mucous membrane of the alimentary 
canal. I am satisfied that my patients live much longer, and are much 
more comfortable, by a judicious repetition of the tapping, with mild tonics 
and diuretics internally, and a judicious regulation of the diet than by 
any other process I have been able to adopt. Of course as the cause of the 
dropsical effusion cannot be removed, and as the reaccumulation generally 
takes place with an increased degree of rapidity as the case progresses, the 
blood eventually becomes so impoverished, that the patient's strength gives 
way, the tissues everywhere become imperfectly nourished, and he dies in 
a majority of instances from asthenia. And yet in a considerable number 
of cases the final termination is hastened or occurs somewhat suddenly by 



SPLENITIS. G03 

perversion of the action of the kidneys, retention of the urine, poisoning 
of the nervous centers and the supervention of convulsions and coma; or 
cona and death without convulsions. Sometimes hemorrhages take place 
in the advanced stage, either from the stomach or bowels, leading to sudden 
and fatal results; and occasionally effusioa takes place into the pericardium 
or into the cavity of the pleura, compressing the lungs or interfering 
directly with the action of the heart, and hastening the fatal result by 
either or both of these processes. 



LECTURE LVII. 



Splenitis— Acute and Chronic : Causes, Clinical History. Anatomical Changes, Diagnosis, Progno- 
sis. Trei'meuL; Nephritis— Causes, Diagnosis; Acute Nephritis— Symptoms, Anatomical Changes, 
Diagnosis. 

GENTLEMEN: The spleen being an organ composed largely of con- 
nective tissue and blood vessels, admits of ready congestion, or en- 
gorgement and extreme changes in its circulation, without necessarily 
developing exudation, or true inflammatory action. And, perhaps, no 
one of the internal organs is more frequently involved in some degree 
of hyperemia, with more or less irritation, sometimes extensive ex- 
udation and changes of structure, than is the spleen, during the prog- 
ress of nearlv all of the acute general diseases. As you have noticed, 
while I was speaking of the general fevers and directing your atten- 
tion to the post-mortem appearances and pathological changes pre- 
sented in both the periodical and continued types of fever, the indi- 
cations of morbid action in the spleen were among the most frequent 
and noticeable of any in the cavity cf the abdomen. While this is true 
in regard to those affections of the spleen which accompany general, 
acute or infectious diseases, it is equally true, that primary idiopathic in- 
flammation of the spleen is one of the most rare occurrences that we 
meet with in general practice. Still it occasionally occurs, from general 
exposure to cold and wet as well as from congestions that occur during 
the active stage of other forms of disease. The inflammation may present 
all gradations of activity, from the most acute and rapidly progressive, to 
the more chronic and persistent form. When the spleen is attacked 
with acute inflammation, the symptoms are usually sufficiently character- 
istic to leave little or no doubt in regard to diagnosis. The organ be- 
ing very distensible, the congestion of vessels necessarily constituting 
the first stage of the inflammatory process gives rise to a rapid enlarge- 
ment of it, accompanied by more or less pain, dull and obscure, if the 
inflammation is restricted to the interior texture but more acute, sharp 
and lancinating if it invades the surface covered by the peritoneal mem- 
brane. 

The pain, whether dull or acute, is located in the left hypochondriac 
region, oftentimes near the posterior hypochondrium, shooting upward oc- 
casionally toward the scapula, always increased on taking deep inspira- 
tions, or upon putting the side on the stretch, and still more increased 
by percussion and pressure directly over the region of the organ. Per- 
cussion not only produces decided indications of tenderness, but it also in- 
dicates an enlargement of the area of dullness beyond that which natur- 
ally belongs to the spleen in its healthy condition; and not infrequently 



604 SPLENITIS. 

the enlargement is sufficient to enable you to touch the edge of the spleen 
projecting below the margin of the ribs on the left side by simple palpa- 
tion. Acute inflammation of this organ is sometimes ushered in by 
chilliness, but more frequently without a noticeable chill, unless it is con- 
nected with coincident existence of malarious fever; but, whether there be 
chill or not at the beginning, it soon gives rise to a moderate grade of 
general fever, indicated by rise of two or three degrees of temperature, 
more or less acceleration in the frequency of the pulse and its fullness, 
more than the usual dryness of the skin, frequently some degree of coat- 
ing upon the tongue, sympathetic nausea and not infrequently vomiting 
whenever drink is taken a little too freely. The symptoms thus developed 
in acute splenitis usually continue not more than from three to five days 
under favorable circumstances before they begin to abate. The soreness 
diminishes, the fever gradually disappears, and soon the enlargement is 
found to be diminishing, and at the end of the second week in most cases 
of simple attacks of inflammation, convalescence is established, and the 
organ returns to nearly its natural size. Such is not always the case, 
however, for sometimes after the acute symptoms have progressed for five 
or six days and the spleen has attained a size sufficient to jut two or three 
inches below the margin of the ribs, the pain begins to abate, the febrile 
symptoms diminish, and the patient becomes comparatively comfortable 
in ail respects, except the swelling remains and there also remains a cer- 
tain degree of tenderness to pressure, a sense of weight and heaviness in 
the side, scantiness of urine, a moderate acceleration of pulse, which is less 
firm and less full than at first, but still moderately increased in frequency, 
though easily compressed. Such a case may continue an indefinite p3riod 
of time, the spleen gradually enlarging, until at the end of two or three 
months its lower end will rest upon the concavity of the ileum, or fill 
nearly the whole of the left side of the abdomen. These cases are said to 
have assumed the chronic form. I have seen some instances in which the 
spleen acquired a high degree of density, eventually becoming almost 
destitute of tenderness, but producing a progressive diminution of the 
red corpuscles of the blood and giving the patient a strongly marked 
spanoemic appearance, accompanied by a sense of weakness and inability to 
maintain active exertion. 

There is still another class of cases, occurring chiefly in hot climates, in 
which the attack of inflammation is unusually acute and severe. The swell- 
ing and other symptoms progress rapidly for five or six days when the 
patient is attacked with irregular rigors and sweats accompanied by a small 
and rapid pulse, frequently, more or less delirum, and sometimes epis- 
taxis. The patient loses strength rapidly, in some instances the bowels 
become loose, affording several thin, brown, or bloody evacuations in the 
twenty- four hours, and if no relief is obtained death may supervene from 
exhaustion or from the recurrence of copious hemorrhage either from the 
stomach or the bowels before the end of the second week. On the other 
hand some of these cases, after the recurrence of chills and sweats indi- 
cating suppuration and the formation of abscesses, in a few days discharge 
a large amount of pus by vomiting, showing that an abscess has formed in 
the spleen and discharged its contents into the stomach. I think some in- 
stances are on record in which adhesions had taken place between the 
spleen and extreme left angle of the colon, and abscesses have discharged 
from the spleen into that section of the colon, and, of course the matter made 
its appearance with the evacuation from the bowels. In still other in- 
stances, abscesses have tended to the surface and have formed adhesions 
with the abdominal walls, progressing in that direction till fluctuation was 



ANATOMICAL CHANGES. G05 

distinguishable, and by either free incision, or by aspiration, the pus has 
been evacuated in the same manner as in abscesses of the liver. But sup- 
puration as the result of inflammation in the spleen, is very much less 
frequent than in the liver — so much so that in the whole period of my 
practice I have met with not more than one or two instances that have 
been diagnosticated, either before or after death, as involving suppura- 
tion, or the formation of an abscess in the spleen. Acute inflammation in 
the spleen, whether resulting in suppuration or otherwise is more frequent 
in hot than in the colder climates. 

The subacute attacks of inflammation in the spleen occur frequently 
during the progress of malarious fevers in all countries where such fevers 
are prevalent. Such attacks are usually of the milder type and supervene 
in connection with the chill belonging to the general disease, and are 
almost always so far relieved or modified by the treatment given to the 
general disease that they hardly require or receive separate consideration. 
And yet, from this very fact, there occur now and then cases which do not 
subside under such management, but only become modified by the sub- 
sidence of the pain, tenderness, and other more prominent symptoms, 
while the organ itself remains enlarged from congestion and exudation 
into its texture, and consequently is found in a few weeks or months, 
after the patient has been supposed to be convalescent, still giving rise to 
a sense of heaviness, weight, and sometimes dull pain in the left hypo- 
chondriac region accompanied by impairment of appetite, diminution of 
red blood corpuscles and continued sense of weakness. Wheu examined 
the hypochondriac region on the left side is found more convex than 
natural, presenting a much larger area of dullness than belongs to the 
spleen, and its thick hardened edge is easily felt by palpation below 
the margin of the ribs from the left margin of the epigastric region 
around to the space between the crest of the ilium and lower ribs. 
These are cases in which the subacute inflammatory action established 
during the progress of acute general diseases only partially subsides, 
leaving the connective tissue of the spleen in a state of chronic inflam- 
mation with more or less exudation into the interstitial spaces of the 
tissue. Under continued hyperaemia, or chronic inflammatory action 
the work of sclerosis or hypertrophy of the connective tissue progresses. 
It is from neglect of the earlier stages of these cases, especially in 
malarious fever, and sometimes in the typhoid and typhus grades, that 
the patient is found, oftentimes months and sometimes years after con- 
valescence from the general disease, with a chronic persistent enlarge- 
ment and induration of the spleen. This may continue slowly to pro- 
gress, till, as I have previously said, it fills up the whole of the left side, 
and by its mechanical pressure upon surrounding tissues gives rise to 
much discomfort and blood impoverishment, and ultimately shortens the 
life of the patient. In a few instances the inflammatory affection un- 
doubtedly commences purely in the chronic form, without being preceded 
by either an acute or subacute attack. 

In its early stage the symptoms are somewhat obscure, and often escape 
attention or lead to the suspicion that the patient is laboring under some 
gastric derangement or indigestion, till the organ has attained sufficient 
size and hardness to attract attention by its weight and fullness, and 
direct exploration by percussion and palpation, completes the diagnosis 
and renders the practitioner aware of the true cause of the patient's 
suffering. 

Anatomical Changes. — The spleen when examined during the early 
stage of acute inflammation presents all the evidences of intense engorge- 



606 INFLAMMATION OF THE SPLEEN. 

merit of its vessels, the accumulation of blood causing an increased 
redness and swelling. When cut across, blood ooz3s from its vessels in 
greater quantities than is normal, and all the evidences of copioas exuda- 
tion into the interstitial tissue are present; the exudation being com- 
posed of numerous lymphoid cells, migrating corpuscles, more or less red 
corpuscles, fibrillated fibrine, and liquor sanguinis, produce varying degrees 
of density in the structure of the organ. In most cases where an acute 
inflammation has supervened as a complication of acute general disease, the 
texture of the organ is soft or impaired; when not connected with a general 
disease, but occurring from ordinary exposure as a form of acute infltm- 
mation, the liquor sanguinis exuding into the interstitial spaces of the tissue, 
is more firmly coagulable or plastic, the connective tissue itself undergoes 
more rapid hepatization and hypertrophy, and the density of the organ is in- 
creased. As a general rule in such cases, the density will be increased 
in proportion to the duration of the disease; consequently when it assumes 
the chronic form the connective tissue becomes greatly thickened, hyper- 
trophied by the addition of plastic material, and the interspaces become 
filled with lymphoid cells of various sizes and shapes, not only giving 
rise to great engorgement of the organ as a whole, but giving to its 
texture much greater density and firmness. 

In nearly all these cases, however, the exterior of the spleen retains its 
smoothness and evenness of surface. 

Diagnosis. — As I have already intimated, the diagnosis of acute inflam- 
mation of the spleen is not difficult or obscure. The sudden development 
of acute pain, tenderness to pressure on percussion, more or less general 
febrile movement, and particularly in addition to this, the rapid enlargement 
of the organ, as indicated by an increased area of dullness on percussion, 
leaves no room for doubt as to the nature and seat of the disease. From 
pleurisy it is of course distinguished by the fact, that the pain, enlarge- 
ment and fullness are all located below the attachment of the diaphragm, 
and the further fact, that there is neither friction sound coincident with 
the respiratory movements on that side of the chest, nor dullness extend- 
ing above the diaphragm to indicate any effusion that might exist in the 
second stage of pleurisy. From gastritis it is distinguished by the decided 
difference in the character of the pain, and by the absence of the persistent 
vomiting, acute epigastric tenderness and distension which exist in the 
latter disease, and are not present in the splenitis. But there are some 
cases of chronic inflammation, and enlargement or induration of the spleen, 
in which, after the disease has continued for a considerable length of time, 
there may be some difficulty in arriving at a satisfactory and positive 
diagnosis from the enlargement that belongs to leucocythaemia, per- 
nicious anaemia, sometimes to cirrhosis of the liver, or occasionally 
results from malignant growths in the tissue of the spleen. But if 
you remember that the splenic affection connected with the leucocy- 
thaemia is accompanied by other evidences of the same general dis- 
ease in other glands, coincidently, as was ' described when I treated 
more particularly of that affection, and the same in regard to the coinci- 
dent conditions in pernicious anaemia and cirrhosis, it will enable you to 
keep clear the line of distinction between simple chronic inflammation and 
induration, and splenic affections accompanying the other diseases just 
named. In regard to malignant growths causing enlargement of the 
spleen there are two almost constant points of difference, which should 
engage your attention ; the first is, that malignant growths in the spleen 
commence obscurely with little or no evidence of inflammatory action 
during all their early history, and are accompanied by a much more de- 



INFLAMMATION OF THE PANCKEAS. G07 

cided general cachexia than belongs to ordinary chronic inflammation of 
that organ. The other is that nearly all malignant growths involving the 
spleen cause it to become irregular in its outline, nodulated upon its sur- 
face, some points being more prominent and dense than others, while the 
enlargement from simple inflammation is more general, and preserves a 
more even and uniform condition of the surface. 

Prognosis. — Nearly all the cases either of acute or chronic inflammation 
of the spleen, if brought under judicious management during the early 
period of their progress, terminate favorably. Consequently, there is not 
a very high ratio of mortality resulting from this affection in any grade, 
acute or chronic, except when it has been neglected during the early 
stage, or when, as occasionally happens in warm climates, the inflamma- 
tion has assumed that rapidly advancing and suppurative character that 
corresponds almost directly with what is denominated acute yellow 
atrophy of the liver. But when in the earlier stages of their progress, 
chronic cases have been neglected until the organ has acquired a large 
size, and greater density of structure, it is very liable to remain an in- 
definite period of time without undergoing resolution by any process of 
treatment that has 3^et been devised. Still, life may be prolonged many 
years. When it does terminate fatally, it is more generally from the 
effects of mechanical pressure interfering with the function of surrounding 
organs, than from direct influence of the disease of the spleen itself. 

Treatment. — In regard to the treatment of all grades of inflammation of 
the spleen, I need do no more than remind you that the same principles 
and the same remedies are applicable here as in the treatment of corre- 
sponding grades of inflammation in the liver. I have not been enabled to 
detect any essential difference in the effects of remedies, or in the necessity 
for their use, between the corresponding grades of inflammation in the 
liver and in the spleen; consequently we will not repeat here what was 
said with a sufficient degree of detail in the preceding lecture. 

Inflammation of the Pancreas. — That the pancreas is sometimes the 
seat of inflammatory action there can be no doubt. In many instances, 
in making post-mortem examinations where the patient has suffered dur- 
ing life from inflammation within the abdominal cavity, the pancreas has 
been found to present all the evidences of acute or subacute inflammation. 
That it is very rarely the primary seat of this form of disease is also un- 
doubtedly true. Its deep-seated position makes it difficult to trace 
its outline unless it be greatly enlarged or indurated, and difficult 
to determine whether any given pain or tenderness is located in that 
organ, or in any of the textures or viscera surrounding it. That some of 
the cases with which we meet of very obscure and persistent derangements 
of the later stages of digestion, or of the changes that naturally take place 
in the duodenum, as well as the rare cases of diarrhoea, characterized by 
fatty dejections, are connected with an inflammatory condition of the 
pancreas, I have no doubt. Some writers have reported a few cases of 
sudden death in which the only post-mortem appearances were the pres- 
ence of acute inflammation of the pancreas. In other cases of chronic 
disease terminating fatally, post-mortem examinations have revealed 
various degenerative conditions of the pancreas, in some instances, fatty 
degeneration of its texture, in others sclerosis, or hypertrophy of the 
connective tissue. Perhaps the most frequent disease that is seen of a 
non -inflammatory or malignant character consists of the scirrhus or col- 
loid form of cancer, chiefly occupying the head of the pancreas, and gen- 
erally connected with scirrhus of the pylorus, or of the adjacent tissues. 

Two instances have come under my own observation, of scirrhus of the 



003 NEPHRITIS. 

pancreas, causing the head of it to become twice its natural size, to be easily 
felt through the walls of the abdomen, and recognized as belonging to the 
pancreas, rather than the pylorus or other tissue by the elongation of the 
tumor transversely in reference to the abdomen, and at the same time the 
absence of some of the symptoms of obstruction in the pyloric orifice, that 
usually accompany cancers in that part. There are no well established 
diagnostic symptoms by which you can recognize the various inflammatory 
conditions of the pancreas, and consequently it would be futile in the pres- 
ent state of our knowledge to undertake the consideration of them more 
in detail. I shall, therefore, next direct your attention to the inflamma- 
tions of the kidneys, and other portions of the urinary apparatus. 

Inflammations of the Genito- Urinary Organs. — Under the designation 
"genito-urinary organs" is included the kidneys, urinary passages, and 
the male and female organs of generation. But the universal custom of 
considering diseases affecting the female organs of generation in works 
upon midwifery and gynecology, and those of the male organs including 
the urinary passages and bladder, in works upon surgery, remove the con- 
sideration of these from the field of practical medicine; consequently 
there is left for us to consider only the inflammations affecting the kid- 
neys. 

Nephritis. — In considering the inflammatory conditions of these impor- 
tant organs it will be convenient to group them under the following heads: 
simple hyperemia or renal congestion, acute and chronic diffuse 
nephritis, and acute suppurative nephritis. Hyperemia, or con- 
gestion of the texture of the kidney, may occur from three sep- 
arate pathological conditions; first, from directly increased determina- 
tion of blood, causing the condition properly denominated active 
congestion; second, from paralysis, or diminution of the vasomotor 
influence over the arterioles of the kidneys, by which they are allowed to 
dilate and receive more blood than normal, and third, similar vasomotor 
paralysis or impairment of the venous radicles, by which the blood accu- 
mulates in the venous side of the circulation in those organs. The causes 
which may give rise to these various forms of hyperemia of the vessels of 
the kidneys are various. The first or active grade of hyperemia most 
frequently results from the action of irritating substances taken into the 
stomach, and carried to the kidneys for elimination; such as the slighter 
grades of irritation arising from cantharides, turpentine and other sub- 
stances, that are capable of being eliminated freely from the blood through 
these organs, and are more or less irritating in their influence. 

It is probable, also, that these forms of disease may originate from con- 
stant exposure to cold, sudden wetting, over-heating, or warmth. The 
causes capable of giving rise to paralysis of the vasomotor nerves belong- 
ing to the arterioles of the kidneys are well understood; but the hyper- 
emia of the smaller veins, constituting what some writers term true pas- 
sive congestion of the external portion of the kidney, originates or may 
originate from all those pathological conditions which interfere materially 
with the oxygenation and decarbonization of the blood. It is therefore 
this form of renal congestion that occurs frequently in connection with 
such structural diseases of the heart as induce more or less constant over- 
fullness of the vessels of the lungs, the advanced stages of phthisis, some 
cases of pneumonia, the typhoid grades of general acute diseases, and 
any of the general dropsies, which proceed far enough to produce 
dyspnoea, or cardiac obstruction, and thereby lessen the amount of 
oxygen taken up and of carbonic acid gas eliminated through the lungs. 
You will thus perceive that passive congestion of the kidney occurs 



SYMPTOMS. 609 

almost exclusively us a secondary affection resulting from serious 
prior diseases, and not as a primary affection. In a large proportion of all 
the cases of acute general disease that terminate fatally, especially those 
of an infectious character, post-mortem examination shows more or less 
passive congestion of the kidneys. When renal hyperaemia arises from 
prior acute diseases, it attracts no more attention than any other second- 
ary functional derangement, usually disappearing with the subsidence 
of the cause with which it is associated. On the other hand, when a con- 
gested condition of the kidney remains, after the subsidence of the 
cause that may have induced it, there is danger that it will so far inter- 
fere with the elimination of the natural elements of urine as to allow the 
blood to retain an excess of these elements and lead to some one of the 
more serious consequences of uraemic poisoning, such as violent vomiting 
and purging, or the sudden occurrence of convulsions, followed by more or 
less paralysis, and sometimes by coma and death. It is necessary, therefore, 
that attention be given in all cases to the condition of the kidneys during 
the progress of such diseases as interfere with the respiratory function, 
either directly or indirectly, so far as to impair the function of the vaso- 
motor nerves connected with the renal vessels. The symptoms which 
indicate renal hyperaemias during life vary with the varying pathological 
conditions that I have already mentioned. Perhaps in all cases of active 
determination of blood to the kidney, under the influence of irritating 
agents, the urinary secretion is decidedly diminished in quantity, usually 
redder than natural, containing less urea, and, for a time at least, some 
albumen. The hyperaemia dependent upon dilatation of the arterioles is 
more frequently accompanied by increased flow of urine above the natural 
standard. Indeed, some writers have considered the real c :use of dia- 
betes insipidus to be a paralyzed and passively congested condition of the 
arterioles. The urine, however, while increased in quantity, has a low 
specific gravity, seldom contains any abnormal elements, but simply a 
large excess of water in proportion to its solid constituents. The exces- 
sive flow of water diminishes the watery element of the blood, often giv- 
ing rise to increased thirst, more or less shrinking of the tissues, or emaci- 
ation, generally decided loss of strength, or power of endurance, and 
much wakefulness, and other symptoms indicating nervous excitability. 
It is undoubtedly this form of hyperaemia of the kidney depending upon 
dilatation of the arterioles that gives rise to the copious secretion of lim- 
pid urine, so characteristic of many cases of hysteria. On the other hand, 
in those cases of renal hyperaemia dependent upon impairment of the 
vasomotor influence over the renal veins, there is almost uniformly a dim- 
inution in the quantity of urine secreted. Frequently it is of a dark, 
brownish color, sometimes containing epithelial cells, often red corpuscles 
of blood, and not infrequently traces of albumen. The quantity of ureas 
is also in these cases very generally diminished. If the congestion is 
connected with the existence of some permanent structural disease of the 
heart or lungs, and consequently not capable of any permanent removal, 
the secretion of smaller quantities of urine, and the consequent favoring 
of the accumulation of the watery element of the blood in the vessels, in- 
creases the tendency to general dropsical infiltration of the areolar tissue 
in all parts of the body. Consequently, if no dropsical effusions have ex- 
isted prior to the occurrence of this form of renal congestion, it is soon fol- 
lowed by the development of some indications of general oedema. This 
is seen first in the morning, when the patient rises from the bed, more no- 
ticeably in the face and loose tissues of the eyelids, and more prominently, 
39 



010 ACUTE DIFFUSE NEPHRITIS. 

if the patient sits up during the day with the feet in a dependent condi- 
tion, in the tips of the feet and ankles. And ultimately the renal congestion 
continues, general dropsy and infiltration of the areolar tissues throughout 
the whole system almost necessarily follows. As this general anasarca 
increases throughout the system the urinary secretion becomes less 
and less in amount, till oftentimes the elimination of urea is so sir all that 
the symptoms of uraemic poisoning supervene, and frequently hasten the 
fatal termination of the case. The anatomical changes which result from 
this hyperaemic condition of the kidnev vary much, both from the vary- 
ing degrees of intensity of the congestion and its duration. Perhaps in 
all cases of active congestion the kidney is somewhat increased in size, 
and presents more or less of a mottled color; portions of it being paler 
than natural, while other parts are deep red, or of intermediate shades of 
color. Those cases dependent on venous congestion almost always pre- 
sent a moderate degree of enlargement of the kidney, with a dark red ap- 
pearance of the pyramidal bodies, some degree of exudation in the mal- 
pighian tufts, and around the glomeruli, and sometimes a slight extravasa- 
tion of blood. 

Diagnosis. — The diagnosis of the different grades of hyperemia, or renal 
congestion, depends mainly upon the coincident condition of the patient 
in relation to other diseases, and the direct quantity or quality of the urine. 
It is rare that in any of these cases there is sufficient pain, either in the 
region of the kidneys or on evacuating the water, to attract attention, or 
to indicate the pathological condition. Sometimes, however, when active 
congestion arises from sudden exposure to cold, or from the existence of 
direct irritating substances circulating in the blood, there will be a mod- 
erate degree of dull, aching pain directly in the region of the kidneys, 
sometimes shooting downward in the direction of the ureters. Unless 
the hyperemia continues until it develops active inflammation, the pain 
is only moderate and of temporary duration, while the condition of the 
urine will aid in establishing a diagnosis. In the first class of cases it is 
small in quantity, with a diminished proportion of urea, and very gen- 
erally contains some traces of albumen, with occasional fibrinous casts, 
but usually less than in actual nephritic inflammation. The characteristic 
condition of the second form of congestion, dilatation of the arterioles, is 
increased flow of urine with less than the normal proportion of urea, and 
other natural excretory elements of urine, and an entire absence of morbid 
elements of any kind. The third is characterized by diminution of the 
amount of urinary secretion, its darker color, more generally slight traces 
of albumen, fat granules, and frequently traces of red corpuscles of the 
blood. These conditions are generally associated with more or less gen- 
eral dropsy, or with the last stages of wasting suppurative diseases. Of 
the treatment of these hypeiasmias it is unnecessary to speak till we con- 
sider the different grades of inflammation of the kidney. 

Acute Diffuse, Nephritis, or Acute BrigMs Disease. — Acute inflamma- 
tion, invading the structure of the kidney generally, constituting what we 
have designated as acute diffuse nephritis, seldom occurs as a primary or 
idiopathic affection, but in far the larger number of cases, it occurs either 
during the progress, or as the sequel, of some one of the acute general dis- 
eases of an infectious character. Perhaps three fourths of all the cases 
met with in general practice originate in connection with, or during con- 
valescence from, scarlet fever. Less frequently it follows the other erup- 
tive fevers, such as measles, small-pox and erysipelas. Occasionally cases 
occur during the convalescing period from both typhoid and typhus fevers, 
but very rarely from the other general febrile affections. When the dis- 



SYMPTOMS. Gil 

ease originates idiopathically, or independent of the prior existence of 
other diseases, it is generally caused by the direct impression of cold and 
damp. Sleeping in cold or damp rooms or beds, going into the water 
when the body is at a high temperature from previous exercise, or becom- 
ing thoroughly wet, and then suddenly chilled, are conditions most likely 
to cause an attack. This form of disease is also capable of being in- 
duced by the action of direct irritants. The introduction into the system 
of cantharides, either by the mouth or absorbed from blistered surfaces, 
oil of turpentine, oil of mustard, cubebs, carbolic acid, and a variety of 
other substances, have occasionally been found capable of producing direct 
irritation and inflammation of the renal structure. 

Symptoms. — Whatever may be the direct cause, whether it be the con- 
ditions growing out of previous diseases, the direct irritants introduced 
into the svstem, or the impression of cold and damp upon the surface, the 
symptoms which indicate the comuiincement of an acute attack of nephri- 
tis, are usually well marked. They consist of pain pretty severe in 
the back and loins, increased by motion or turning the body, acceleration 
of pulse with increased fullness, decided increase of temperature of the 
body, more frequent respirations, considerable thirst, much restlessness, 
an expression of anxiety in the countenance, and a very decided diminution 
in the quantity of urine secreted. Sometimes the desire to urinate is ac- 
companied by a sense of heat, at other times by no apparent local irrita- 
tion in the urinary passages, and the urine passes only at regular intervals 
and in very small quantities — what is passed is usually either of a turbid 
appearance, or redder than natural, and pretty uniformly yields a copious 
precipitate of albumen upon the application of heat or nitric acid. If the 
urine be further analyzed, it will be found to contain decidedly less than 
the natural proportion of urea and excretory elements of urine, while the 
microscope will usually detect more or less red corpuscles of the blood, 
fibrinous casts, shreds of solidified fibrin, and usually some epithelium, 
evidently from the urinary tubles. The assemblage of symptoms which 
I have described, leave no reasonable doubt as to the existence of some 
degree of diffuse nephritic inflammation. If it is not speedily relieved, 
additional symptoms of striking importance follow. In the more acute 
class of cases, within twenty-four hours from the commencement of the 
attack, the retained urea will be found to manifest its irritant effects, 
either upon the mucous membrane of the digestive organs, or perhaps 
more frequently upon the nervous centers. If upon the first, there is 
vomiting, active and severe, followed not infrequently by copious watery 
diarrhoea, rapidly exhausting the patient, and giving the case much 
the appearance of genuine cholera morbus ; while in the second class 
of cases, in which the irritant effects are developed in the nervous 
centers, there is first jerking of the muscles, sudden motions of the 
limbs, some degree of delirium, and if no modification of the progress 
of the disease is made by treatment, during the latter part of the second 
or the third day, in a large proportion of the cases, general convulsions 
will occur. Sometimes the first severe general convulsion is followed 
by coma, dilated pupils, stertorous breathing, entire suppression of the 
urinary secretion and death in a few hours. At other times the convul- 
sion after a few minutes ceases, leaving the patient drowsy, breathing 
heavily, and after from ten to thirty minutes, consciousness is regained, 
and for a time varying from a few minutes to two or three hours, the 
patient will appear much as before the convulsion occurred, when sud- 
denly another paroxysm will occur, of the same character as the first, fol- 



012 ACUTE DIFFUSE NEPHRITIS. 

lowed by the same results, only leaving the patient more dull and de- 
pressed, the pulse quicker, smaller than usual, the extremities cooler, with 
a constant puffiness of the face, some general tumefaction, especially 
of the hands and feet, producing the appearance of a moderate degree 
of oedematous infiltration into the areolar tissue. The urinary secretion 
is now usually exceedingly small and so highly albuminous as to form a 
coagulum, almost like the white of an egg. Very frequently also more 
decided quantities of blood appear in the urine. The patient may now 
pass into another convulsion, ending in entire coma, collapse and death, or 
without further convulsions, the breathing may become more labored, irreg- 
ular and sighing, the mind more dull, making it difficult to arouse the indi- 
vidual, pupils steadily dilated, very frequently the axes of vision are not par- 
allel, the eyes being turned in different directions, and one pupil possibly 
more dilated than the other. Often one arm and one leg are found entirelv 
paralyzed, while there are frequent automatic movements of the other, 
such as drawing up the leg, putting it down, and tossing the hand in 
different directions. And by the fourth or fifth days entire coma super- 
venes, accompanied by involuntary discharges from the bowels, entire 
suppression of the urine and an early death. The progress of these cases 
varies much in different patients. I have seen some cases terminate 
fatally within thirty-six hours from the first appearance of the renal 
trouble, by violent convulsions and coma. Others have been so slow as 
to reach a fatal result only at the end of from seven to nine days. More 
frequently, when they terminate fatally in the acute stage, death super- 
venes between the end of the second and the commencement of the fifth 
day. The symptoms of acute nephritis, as I have just described them, 
are more particularly applicable to that class of acute cases which follow 
scarlatina, and the convalescing stage of other eruptive diseases. Almost 
identically the same assemblage of symptoms and succession of changes 
and results take place in those cases of acute nephritis that occur in 
the latter stages of pregnancy, and sometimes culminate at the time of 
delivery, giving rise to what is denominated puerperal convulsions or 
eclampsia. 

I recollect two cases of acute nephritis caused directly by the influ- 
ence of cold and wet: One was a laboring man, working upon the open 
prairie in the latter part of summer, and camping out during the night 
with imperfect protection, who suffered a thorough wetting from a copious 
shower of rain during the night, followed by a sudden change in the tem- 
perature of the atmosphere. In this case, within twenty-four hours aftei 
the wetting, the patient was taken with severe dull pain in the loins 
and directly opposite the two lower ribs and their junction with the 
spine. Pain was increased by moving the body; febrile reaction took 
place sufficient to cause the temperature to rise to 30° C. (102° F.); 
the skin was dry and hot, face suffused with redness, puffiness under 
the eyes, a heavy dull pain in the frontal region of the head, a white coat 
upon the tongue, pulse 110 per minute and moderately full, bowels quiet, 
and the urinary secretion exceedingly small, not more than from two to 
four ounces being voided three times during the twenty-four hours pre- 
ceding my visit. On examination, the urine contained a large proportion 
of albumen, some fibrinous shreds, and a considerable number of red cor- 
puscles of the blood. By active treatment, this case was relieved in 
three or four days, and ultimately so far recovered as to leave no perma- 
nent injurious consequences. Another case, originated from getting the 
feet wet and cold near the period of menstruation. It happened to the 
mother of a. family, aged about thirty-five years, in whom the attack was 



ANATOMICAL CHANGES. 613 

characterized by pain in the back, extending more or less to the limbs. 
Almost immediately drowsiness occurred, and such a disposition to sleep 
that Bhe was incapable of being aroused sufficiently to fix her attention on 
anything. There was increased heat of skin, a quick, rather sharp pulse, 
but the respirations were slow, variable, sometimes sighing. There were 
slight jerkings of the muscles, but no general convulsions. From the 
early appearance of dullness, approaching stupor, the patient made but 
little complaint, and consequently her danger was not discovered till the 
disease had progressed thirty-six hours from the time of its commencement. 
At that time I found her in the state I have just described. She had passed 
no more than two ounces of urine in the previous twelve hours. This, on 
examination, contained so large a proportion of albumen, that when to a 
small quantity in a test tube was added a few drops of nitric acid, the co- 
aguium occupied the whole space. This patient proceeded directly and 
rapidly to complete coma; dilatation of the pupils occurred, paralysis of the 
sphincters, involuntary discharges from the bowels, and death on the third 
day. This case will serve to illustrate some of the features of the disease, 
and especially to impress upon your minds the extreme danger which ac- 
companies acute attacks of nephritic inflammation. You will perceive that 
the chief characteristic symptoms are the marked diminution in the quan- 
tit}- of urine, the appearance of albumen in it, coincident with diminution 
in the proportion of urea and excretory elements; the almost immediate 
appearance of more or less puffiness from cedematous infiltration into the 
subcutaneous areolar tissue, more especially of the face and eyelids, tops 
of the feet about the malleoli of the ankles and backs of the hands. Sub- 
sequently there is a filling up of the areolar tissue almost universally 
throughout the system from serous infiltration. To these must be added 
an almost constant tendency to develop symptoms of uragmic poisoning, 
either in the digestive organs or nervous centers. 

Anatomical Changes. — The anatomical changes presented on making 
post-mortem examinations of patients having died from acute diffuse 
nephritis, differ much. The most constant of these changes are altera- 
tions in the color and size of the kidney; the organ being pretty uni- 
formly moderately increased in size, and more vascular, that is, con- 
taining a larger amount of blood than natural. Yet there is seldom 
that intense red color which characterizes most of the textures of the 
body in a state of acute inflammation. But there are limited portions of 
the cortical texture of the kidney and of the pyramidal bodies that are of 
a deep red color, while others are perhaps paler even than natural. Close 
examination will also show, in nearly all the eases, more or less hemor- 
rhagic exudation, or mild extravasations of blood, especially about the mal- 
pighian tufts, and around the glomeruli. The microscope will show more 
or less of the migrating or white corpuscles in the interstitial spaces of the 
tissues, disturbance of the epithelium in the urinary tubules, the presence 
in them, also, of more or less of the fibrinous casts, hyaline bodies, altered 
epithelial cells, very generally some fat granules, and hypertrophy of the 
connective tissue. The most characteristic anatomical changes are, the 
mild hemorrhagic exudations, fibrinous casts in the tubules, accumula- 
tions of exuded liquor sanguinis in the malpighian bodies and around 
the glomeruli, the latter of which are not infrequently blocked up, 
while the alterations in color and size are much more variable. The 
texture of the kidneys, as altered in acute nephritis, is softer than natural, 
and the capsule easily detached. 

Diagnosis. — The principal diagnostic symptoms I have already speci- 



G14 ACUTE DIFFUSE NEPHRITIS. 

fied, when speaking cf the clinical history of the disease, and need not 
repeat them at this time. 

Prognosis. — Although acute diffuse nephritis is a severe and dangerous 
malady, liable to occur at any period of life, and if left to itself extremely 
liable to terminate unfavorably, yet under prompt and judicious treat- 
ment the larger proportion of cases recover. But such are the conse- 
quences of interfering with the depurative action of the kidneys, that 
often under the best of management a considerable ratio of mortality 
will attend the more severe attacks of this disease. As a general rule, so 
long as the amount of urine secreted, and the proportion of urea con- 
tained in it, is sufficient to prevent the development of symptoms of 
uragmic poisoning, the prognosis may be considered favorable. If the 
case proceeds so far as to develop the consequences of retention of urea 
and the excretory elements of the urine, so far as to induce either the 
preliminary nervous startings, or any degree of general convulsive move- 
ments, the danger must be admitted to be grave. Yet a considerable 
number of cases, after proceeding to this extent, will be found to yield 
promptly to judicious treatment. There is some tendency in the acute 
form of diffuse nephritis to partially subside, and end in the chronic form 
of the disease. When it does so, although life may be prolonged many 
months and sometimes two or three years, the patient seldom mak.s an 
entire recovery but ultimately succumbs, under the effects of general 
dropsical infiltrations, first, into the areolar tissues and subsequently into 
the serous sues or cavities of the body. 

Treatment. — In the treatment of those cases which are described 
under the head of hyperasmia or congestion of the kidneys, it is necessary 
to exercise proper discrimination in regard to the special pathological 
conditions which may give rise to the accumulation of blood in those 
organs. It will readily occur to you that a case of hyper re mia, caused by 
active determination of blood to the kidneys, would require very different 
treatment perhaps from a passive hyperasmia originating from diminution 
of vasomotor influence over either the veins or arterioles. When cases 
are met with of the first variety — that is, depending upon active deter- 
mination of blood, and yet not having advanced to the stage of true 
inflammation, it is usually sufficient to commence the treatment by the 
application of dry cups to the loins, and the administration of some com- 
bination that will lessen the force and frequency of the arterial circula- 
tion, and at the same time promote moderate evacuations from the bowels. 
A solution of the bitartrate of potassium, in the proportion of ten grams 
to one hundred and eighty cubic centimeters of water, may be made, of 
which the patient can take eight cubic centimeters, or an ordinary dessert- 
spoonful every four hours, until it shall promote moderately free evacua- 
tions from the bowels. If there is considerable general febrile movement, 
with some degree of acceleration and fullness of the pulse, it will increase 
the efficacy of the remedy if four minims of the tincture of veratrum 
viride is added to each dose of the solution of the bitartrate. Usually, 
this medication results within the first twenty-four hours in procuring an 
increased flow of urine, two or thr e free evacuations from the bowels, 
and, in most cases, of simple, active, renal hyperemia, will afford all the 
relief that is necessary. Cases which may have resulted from the taking 
of some irritating substance as cantharides, turpentine, etc., may be 
treated in the same manner as just mentioned, accompanied by the free 
use of diluent drinks, such as mucilage of slippery elm (ulmus fulva), gum 
arabic, or flax seed. In those cases of renal hypeiaemia dependent on 
impairment of vasomotor influence, which constitute the most common 



TREATMENT. 615 

class of cases, arising, as previously described, from imperfect oxygena- 
tion and decarbouizatiou of the blood, much of the treatment must consist 
in the administration of such remedies as are calculated to mitigate the 
severity of the primary disease, of which the renal trouble is oidy a com- 
plication. In addition I have found, in almost all the cases in which 
digitalis could be well borne, that it constituted a valuable remedy, both 
by its influence in increasing the force and steadiness of the heart's action 
and in encouraging increased secretory activity in the structure of the 
kidney. In some instances, I have derived much advantage by combining 
digital in and ergot in in moderate doses, and giving them at intervals 
varying from once in four to once in six hours. 

In the cases dependent on alteration in the vasomotor influence over 
the arterioles of the kidney, accompanied by increased flow of urine, 
occurring most frequently in nervous and hysterical conditions, the most 
appropriate remedies are such as exert a direct tranquilizing influence 
over the nervous excitability. The bromides, the hydrate of chloral, the 
different preparations of valerian, and sometimes, though rarely, moderate 
doses of the compound powder of opium and ipecacuanha with camphor, 
given at night, will constitute the remedies that usually succeed, unless 
the case has gone so far as to constitute actual diabetes insipidus, or a 
habitually increased flow of urine. If it has assumed that form, the use of] 
these remedies, in connection with the use of full doses of ergotin, will 
usually be found most efficient. When the renal affection passes beyond 
the stage of hyperemia, and constitutes an attack of inflammation of an 
acute character, the appropriate remedial agents must be well chosen, and 
applied with promptness, in order to secure the best results in behalf of 
the. patient. In young, vigorous subjects, especially of a sanguine tem- 
perament, if the attack has come on suddenly by exposures to cold and 
wet, and the general febrile reaction is active and well marked, there is 
no doubt but that one free venesection is beneficial, and can hardly be 
omitted, with full justice to the patient. If, however, venesection is not 
deemed advisable, the application of leeches, if they can be commanded, 
in numbers suited to the age of the patient and the gravity of the disease, 
wdl be the next most efficient remedy at the commencement of the attack. 
The leeches may be applied directly over the region of the kidneys, and 
after they have filled and fallen off, the bleeding from the bites may be 
promoted by the application of warm, wet cloths. In several instances, 
where leeches were not readily at command, the application of dry cups, 
producing a strong revulsive effect over the lower part of the dorsal and 
upper lumbar regions, has been productive of some degree of relief. At 
the same time that these measures are being carried out, it is well to open 
the bowels freely, and give, in addition, such remedies as are calculated 
to lessen general febrile excitement, and promote, as much as possible, 
eliminations from the skin, thereby preventing the accumulation of urea 
and other effete constituents in the blood, whiie the action of the kidneys 
is restrained by the inflammation. Although many writers and teachers 
have objected to the use of mercurials in renal affections, my own experi- 
ence has been decidedly in favor of giving, as early as possible, a powder 
containing three decigrams (gr. v) each of calomel and nitrate of potas- 
sium, and repeating it every three hours, till four doses are taken, unless 
it sooner produces a free movement of the bowels. If, when it comes 
time to take the fourth or fifth dose, no evacuations have taken place from 
the bowels, I substitute, in the place of the powders, either the liquid 
citrate of magnesia, Rochelle salts, or the sulphate of magnesia., and con- 
tinue their use until free evacuations have been obtained. In the mean- 



616 ACUTE DIFFUSE NEPHRITIS. 

tinio, if, as often happens when the disease comics on suddenly and 
actively, following some one of the eruptive fevers, and the urinary secre- 
tion is extremely small, pulse rapid, breathing hurried, skin hot, I have 
given between each of. the doses of calomel and nitrate of potassium a 
sedative and diaphoretic mixture, consisting of the liquor ammonia 
acetatis sixty cubic centimeters (fl. |ii), spirits of nitrous ether thirty cubic 
centimeters (fl. |i), and tincture of veratrum viride four cubic centimeters 
(fl. 3i), of which four cubic centimeters (fl. 3i) may be given well diluted 
with sugar and water between each of the doses of the powder previous! v 
mentioned. I have sometimes, instead of giving this mixture, derived 
greater advantage by giving bitartrate of potassium and digitalis in com- 
bination, either in the form of infusion of the digitalis leaves in which the 
bitartrate is dissolved, which I think is the best method, or a solution of 
the bitartrate in water with the fluid extract of digitalis added in 
proper proportion for efficient action. The objects, as you Avill perceive, 
are to get, as early as possible in the progress of the disease, a free opening 
of the bowels, relying chiefly for that purpose upon the calomel and 
nitrate of potassium, aided, if need be, by a saline cathartic, to lessen the 
force and frequency of the circulation, and promote elimination from the 
skin, by either the digitalis and bitartrate, or the veratrum viride or 
aconite in connection with the liquor ammonia acetatis. By the bleeding, 
general or local, the free action of the bowels and skin, coupled with some 
sedative influence upon the arterial circulation, it is often the case that 
the fullness of the vessels of the kidney become relieved, and in from 
twenty-four to thirty-six hours all the symptoms of the patient are much 
ameliorated. The urine becomes more copious, with much less albumen 
in it; the fever abates, and it is only necessary to keep a moderate 
influence of the diaphoretics and sedatives through two or three subse- 
quent days to complete the relief. The use of such tonics as tincture of 
the chloride of iron will then hasten the recovery of the patients from the 
state of anaemia and debility in which they are apt to be left. 

And if, after the remedies just mentioned have been pushed for the 
first twenty-four hours, free evacuations have been obtained from the 
bowels, yet the amount of secretion from the kidneys remains very scanty, 
or somewhat tinged with blood, and the initial symptoms of uraemic 
poisoning begin to show themselves, such as twitching of the muscles, 
more or less dullness, stupor, wandering of the mind, with increasing 
oedema, of the face, it may be well to administer pilocarpine, or the in- 
fusion of the leaves of the jaborandi, in sufficient doses to produce its 
specific effects upon the skin and salivary glands, with the hope of pre- 
venting further accumulation of the elements of the urine by eliminating 
them through the skin and mucous membranes, thereby giving further- 
time for obtaining relief of the inflammatory action in the kidneys. I 
recollect no case coming under my own observation, in which, if the active 
treatment that I have indicated has been instituted promptly during 
the first twelve hours after the commencement of acute renal disea: e, 
relief has not been obtained, and before the patient has suffered 
from any paroxysms of convulsions, or serious derangement of the 
cerebral functions. But I have met with many cases, where, during the 
first twenty-four hours active measures were not instituted, in which the 
patients, when coming under observation were already exhibiting all the 
symptoms of commencing uraemic poisoning, either by drowsiness, jacti- 
tations, twitching of the tendons, extensive ©edematous infiltration into 
the areolar tissue over the greater portion of the surface of the body, 
extreme diminution of the renal secretion, and sometimes active convu!- 



TREATMENT. 617 

sions. When called thus late, the pulse is usually beginning to assume 
a small ami rapid character, there is some alteration in the pupils, and 
altogether a condition which seems to contra-indicate the abstraction of 
blood. Yet occasionally at that late period, free dry cupping over the lower 
part of the back and loins has still been of advantage. But the great object 
in such cases has been to procure speedy and thorough evacuations 
through the skin and alimentary canal. To procure thesj, if the pulse 
is not too weak, I give sufficient pylocarpine to cause an early and full 
perspiration, and follow it directly with one moderately full dose of 
calomel and nitrate of potassium. If it does not operate in from two 
and a half to three hours, I administer a saline cathartic, and in the mean- 
time have an infusion of the digitalis leaves with bitartrate of potassium 
prepared, so that as soon as the patient is fairly over the action of the 
pylocarpine, and the movement of the bowels, it can be given in such 
doses as will be tolerated. If you put eight grams of the bitartrate 
and an equal amount of the digitalis leaves into 200, c. c. of boiling 
water, stirring them occasionally till the infusion becomes cool, a table- 
spoonful of this may be given at first every two hours to adults and 
smaller doses proportioned to the age in children, watching its effects 
closely. If the specific effects of digitalis are manifested in rendering 
!,he pulse slow, the dose must be immediately diminished to one half and 
the length of the intervals between the time of administration doubled, 
thereby avoiding the exaggerated effect of the digitalis upon the pulse 
and respiration. I could enumerate a considerable number of cases ot 
acute nephritis following scarlet fever, in which the renal affection had 
been permitted to continue unchecked, till severe and repeated convul- 
sions had occurred, and the patient was apparently in an extremely crit- 
ical condition, when the treatment I have just indicated brought about 
entire relief and recovery. I think, gentlemen, you may regard it as a 
positive rule in practice, that when cerebral disturbance, especially in the 
form of convulsive movements, or approaching stupor, coma, and paral- 
ysis, is the result of the retention in the blood of effete constituents of 
urine, or of any other toxagmic agent, little or no advantage will be gained 
by the administration of remedies, simply calculated to diminish nerve 
excitability, or to act as nervous sedatives and anodynes, simply because 
they in no degree either neutralize the toxaeinic agents in the blood, nor 
promote their expulsion. 

It is better, therefore, in all these cases, to direct your attention al- 
most exclusively to the removal of the accumulated retained products on 
the one band, through such channels as nature affords; while on the other 
hand, you leave no efficient means unemployed to relieve the direct full- 
ness and congestion of the vessels in the kidneys. You will occasionally 
meet with cases perhaps in which, after several convulsions, the pulse 
presents that small, irregular quality, the extremities that coolness, and 
the face that pale, bloated aspect which would cause you to hesitate 
about the adoption of active evacuant remedies through fear of exhaus- 
tion. Experience shows that there is far less danger from exhaustion pro- 
duced by efficient evacuations, provided they carry with them the tox- 
emic agents from the blood, than from the continued action of these 
agents, which are already paralyzing the cerebral centers, and endanger- 
ing the life of the patient. As proof of this 1 might relate a number of 
cases: One of comparatively recent occurrence was that of a girl thirteen 
years of age, who had passed through a mild grade of scarlet fever. In 
a' out four days after the subsidence of the general febrile disease, while 
the skin was still rough from desquamation, she began to show symptoms of 



618 ACUTE DIFFUSE NEPHRITIS. 

subacute renal inflammation, which increased steadily for two or three sub- 
sequent days; at which time the urine had become very scanty, and highly 
colored with blood. The usual tests showed a large proportion of albu- 
men in the urine, and there was general serous infiltration or oedema of the 
areolar tissues. In the early part of the evening she was seized with gen- 
eral convulsions. A physician from the neighborhood was immediately 
summoned, and was with her all the night, and until after breakfast the 
following morning. He administered very diligently the bromides and 
chloral alternately, and in combination with moderate doses of digitalis, 
but without apparently in any degree modifying the convulsions, which 
continued to recur. And in the morning, when I saw the patient, invol- 
untary discharges had taken place from the bowels, a very moderate 
quantity of urine had been passed for the preceding twelve hours, the 
patient was profoundly stupid, the axes of vision not parallel, the extrem- 
ities cool, with a very weak, quick pulse. Learning the history of the 
case, and the efforts to control the convulsions by nervous sedatives and 
quieting agents, and the entire inadequacy of the eliminations through 
any channel, I immediately advised that she be put upon powders of cal- 
omel and nitrate of potash, and have them repeated every two hours, with 
a dose of the infusion of digitalis and bitartrate of potassium between, 
taking the two prescriptions alternately, only an hour apart. Soon after 
the third dose of calomel and nitrate of potassium the bowels moved very 
copiously, but such was the unconsciousness of the patient at the time that 
the evacuations took place entirely involuntarily in the bed. No more 
convulsive movements followed, and in less than an hour some urine was 
voided, but as it was passed in bed, the quantity could not be ascer- 
tained. The patient began to breathe more naturally, and after another free 
movement of the bowels the powders were omitted and the digitalis and 
bitartrate were continued alternately with moderate doses of carbonate of 
ammonium and camphor. During the next four hours two more copious 
evacuations occurred from the bowels, and one quite free discharge of 
urine. Before it had passed, the symptoms had so far improved that the 
patient's attention could be aroused momentarily, she could take plain 
nourishment without much difficulty in swallowing, and from that time 
on there was a steady improvement until ultimate, complete recovery took 
place. I am the more particular to dwell upon the necessity of using 
direct and active measures for relieving the vascular fullness of the kid- 
neys at the outset, and the subsequent establishment of those eliminations 
through the skin and mucous membranes as will most efficiently carry off 
the effete materials that are retained on account of the arrest of the func- 
tion of the kidneys; because I have so frequently seen patients whose 
lives were lost during the persistent efforts of the physician to overcome 
the nervous symptoms and convulsions by ordinary antispasmodics, nerve 
sedatives and anaesthetics without any adequate effort to remove the of- 
fending cause existing in the blood and circulating through the nervous 
centers. After the patient is relieved from the more mixed symptoms 
and the function of the kidneys is in a great degree restored, very much 
care is required for several weeks to regulate the patient's diet, causing 
him to avoid all active exertion, either mental or physical, to avoid the use 
of all stimulating drinks, especially of the alcoholic class, and to use such 
tonics as tend to sustain the action of the kidneys and ultimately tore- 
store the tone of the renal vessels to their natural condition. Of the 
tonics, probably none are better than the tincture of the chloride of iron 
during the convalescing stage of these cases. No diet is better than that 
consisting chiefly of milk and farinaceous articles. If, as sometimes hap- 



CHRONIC NEPHRITIS. 619 

pens, the pulse continues to have a quick jerking quality, with softness 
and ready compressibility, showing irritability with diminution of 
strength, or tone in the vessels, moderate doses of digitalis may be con- 
tinued for a considerable time. In some cases I have used ergot, or 
ergotine, in connection with the digitalis, with benefit. 

One measure that is very generally recommended in the first stage of 
these cases, especially in children, I have omitted to mention. I allude 
to the use of the warm bath. In children and young subjects much im- 
portance is attached by many to immersing the patient almost wholly, 
directly at the commencement of the disease, in the warm bath for the 
purpose of producing early relaxation of the skin, as well as exerting 
some revulsive influence from the kidneys. After the patient is taken out 
of the bath, the trunk til" the body is wrapped, especially the loins and ab- 
domen, with napkins or a folded sheet wet in warm water, to which may 
be added the fluid extract or tincture of digitalis so as to bring this 
agent in contact with the skin. By the warm bath followed by the warm 
wet bandage around the trunk of the body, the latter containing more or 
less digitalis, it is supposed that much benefit may be obtained: first, by 
the action of the warmth upon the surface in promoting cutaneous relaxa- 
tion and elimination; and secondly, by some degree of absorption of the 
digitalis through the cutaneous surface. Theoretically, this measure 
should produce decided benefits, and I would encourage its use, especial- 
ly in the early stage of the disease. 



LECTUEE LVIII. 



Chronic Nephritis— Its Causes, Symptoms, Anatomical Changes, Diagnosis, Prognosis, and Treat- 
ment. 

GENTLEMEX: Cases of chronic nephritis are met with in practice 
much more frequently than those of an acute form. In some in- 
stances they are the sequelae or result of a prior acute attack. Much 
more frequently, however, the chronic grade is primary, so far as the renal 
affection is concerned, and in its causation is very generally the sequel or 
completion of prior morbid conditions. Etiologically, the cases of 
chronic nephritis met with in practice may be arranged in four groups; 
the first, which embraces much the smaller number, is the result of im- 
perfectly relieved acute attacks; the second depends directly upon the 
action of some toxaemic or irritant material, either retained in the blood, 
or received in connection with food, drink or medicine; the third origi- 
nates during the progress, or in the convalescent stage of acute general 
diseases, more particularly of the eruptive fevers, and the fourth occurs as 
a complication in the progress of chronic structural diseases, such as cardiac 
affections, pulmonary obstructions and long continued ulcerative con- 
ditions of the mucous membrane of the alimentary canal. The particular 
causes alluded to, as producing the second class of cases, are chiefly such 
agents as cantharides, oil of turpentine, oil of mustard, arsenical prepa- 
rations, carbolic acid, and more frequently than all of these, the habitual 
use of alcoholic drinks. The latter agent probably produces at least two 
thirds of all the chronic cas s of nephritis that are met with in general 



620 CHRONIC NEPHRITIS. 

practice. They are usually alluded to under the name of albuminaria 
or Blight's disease. Concerning the causes constituting the third class, I 
have already commented sufficiently in speaking of the causes of acute 
nephritis. It is probable that this class of cases originate in irritation 
set up in the renal tubules, coincidently with the specific inflammations 
that occur in the cutaneous surface, or in the fauces and glands of the 
neck, and after the subsidence of the general disease, there remains a 
similar disturbed and irritable condition of the renal tubules and secret- 
ing structure of the kidneys as exists in the cutaneous tissue during the 
process of desquamation. It is this impairment of the natural relations 
of the secreting ceils, urinary vessels and uriniferous tubules, that gives 
rise to the congested condition and consequent moderate diminution in 
the elimination of urinary materials. This, if overlooked, gradually in- 
creases from day to day, till in one, two, or sometimes three weeks from 
the time the patient is supposed to be convalescent, he begins to show 
some degree of dropsical infiltration both in the face and extremities. 
And this is often the first thing to attract the attention either of the pa- 
tient or his friends. The mode by which renal disease is established in 
connection with organic or structural disease of the heart, lungs and other 
chronic diseases differs in different cases. In affections of the heart, where 
the kidneys become most frequently involved, it would seem that the renal 
disease begins substantially with the occurrence of venous congestion. 
Obstructing the circulation through the heart causes direct congestion of 
pulmonary capillaries, leading in its turn to defective oxygenation and 
decarbonization of the blood. This causes the blood circulating in the 
structure of the kidney to be deficient in the oxygen necessary for main- 
taining the normal properties of the secreting cells, and, consequently, less 
urine is eliminated. The same condition of the blood causes dilatation of 
the renal vessels, and soon establishes habitual passive congestion with 
some escape of albumen in the urine. The occurrence of this scanty 
secretion of albuminous urine is generally accompanied also by more or 
less epithelial cells, fat granules, hyaline casts, and, of course, causes a rapid 
relative increase in the watery elements of the blood, and the hastening 
on of general dropsical symptoms. It is probable that the renal affection 
and dropsy so often accompanying the advanced stage of all the slow, wast- 
ing forms of disease, have the same origin, namely: the inefficient action of 
the blood in its impaired and impover.shed condition upon the secreting 
cells and vessels of the kidneys, failure of the eliminations is the result, 
and by such failure more water is retained in the blood, and this in its 
turn hastens the general dropsical effusion throughout the system. The 
modus operandi of alcohol in producing chronic renal disease is, in part at 
least, oi a similar character. The daily impregnation of the blood with a 
limited quantity of alcohol diminishes the amount of oxygen taken up 
through the air cells of the lungs, and the carbonic acid gas eliminated. 
Consequently the blood is deficient in its oxygenation and decarboniza- 
tion, and is, therefore, incapable of promoting a natural degree of activity 
in any of the important secreting structures of the body. Indeed it retards 
the natural molecular movements throughout the system and retains the 
organic atoms of the tissues beyond their natural duration and until 
they undergo more or less fatty degeneration. It is thus that the texture 
of the kidneys becomes impaired. Sometimes a decided inflammatory 
action is set up and hypertrophy or sclerosis of the connective tissue 
occurs with desquamation, or casting off of the epithelium. This 
leads ultimately to a contracted granular condition of the kidney, 
which constitutes the typical form of Blight's disease, as originally 



SYMPTOMS. 621 

described by Dr. Brig-lit himself. Tn other instances the degenerative 
changes take more the direction of fatty, amylaceous or waxy degener- 
ation, in which the kidneys, instead of being contracted and firm, become 
large, pule and flabby. With these allusions to the various causes which 
give rise to chronic nephritis, the different pathological conditions which 
are present, you will be ready to infer what is a very important clinical 
fact; that under the head of chronic nephritis there are included in the 
books, and by different writers, a considerable variety of morbid con- 
ditions arising from the action of various causes, differing decidedly one 
from another, and while the general result in the end is, in all of them, or 
nearly all, general dropsy, progressive impoverishment of red corpuscles 
and ultimate death of the patient, yet they reach this final result by some- 
what different processes, and in very variable periods of time. 

Symjitoms. — The symptoms of chronic, diffuse, interstitial nephritis 
vary much, as might be expected from the varying character of the causes 
which are capable of inducing it. In the great majority of instances the 
early symptoms are obscure, and are often either overlooked or misinter- 
preted till in some cases several weeks or months have elapsed, or there 
are indications of ureemic poisoning; and dropsical effusions which first 
attract the attention of the practitioner to the real source of the difficulty. 
In most cases, in the early stage of this form of disease, the patient com- 
plains of little else than simply progressively increasing weakness, of get- 
ting tired easily, of a proneness to mental depression, a variableness of appe- 
tite, and also a variable condition of the digestive functions. Sometimes 
food is taken and digested well, but more frequently digestion is accompa- 
nied by more or less flatulency, and a moderate degree of constipation — the 
latter sometimes alternated with temporary turns of diarrhoea. The patient 
soon presents unusual paleness of countenance, indicating diminution of 
the proper proportion of red corpuscles in the blood, with a puffy or slightly 
swollen appearance of the face, especially on rising from the bed in the 
morning. In most instances in this early stage there are some pains, or, 
more properly, a tired feeling in the back and loins, and a more frequent 
desire to urinate than natural; the urine being for the most part pale in 
color, sometimes abundant, more frequently scanty. Many of this class of 
patients also complain of frequent turns of headache. When the par- 
oxysms of headache are severe, they are usually accompanied by nausea 
and vomiting. With the headache a sense of heaviness and dizziness are 
common symptoms, and sometimes temporary dimness of vision or dark 
spots before the eyes. After these symptoms, or some of them, have con- 
tinued for a variable period of time, often from two to three or four 
months the indications of dropsical effusion become more marked, usually 
first in the face, underneath the eyes in the morning, from which it dis- 
appears partially during the day, but in proportion as it recedes from the 
face the purfiness and swelling of an cedematous character increases in 
the tops of the feet about the malleoli of the ankles and parts most de- 
pendent. Dropsical symptoms having thus begun continue slowly but 
steadily to increase, till there is a more or less pale, anaemic and bloat- 
ed hue of the countenance, while the cedematous infiltration of the feet, 
ankles and legs gradually increases till it occupies the whole of the lower 
extremities, up to the seratum and lower part of the abdomen. At that 
stage of the disease, when the dropsical symptoms become more marked, 
the urine usually becomes more scanty in quantity, sometimes being 
tinged with blood, but more frequently presenting simply a slightly tur- 
bid and pale appearance. The bowels at this stage of the disease are al- 
most always variable, being most of the time inclined to constipation, but 
this is alternated every few days with temporary turns of looseness or 



622 CHRONIC NEPHRITIS. 

slight diarrhoea. Tin digestion of food becomes still more imperfect 
than in the early stage, the appetite also much more variable or lost. The 
disturbances of the nervous system, such as headache, giddiness, tempo- 
rary appearance of spots before the eyes, all become more marked and fre- 
quent than in the early stage. All this assemblage of symptoms con- 
tinue steadily to progress, if not modified by treatment, until dropsical in- 
filtrations come to fill the areolar tissue beneath the skin over almost the 
entire surface of the body; being most prominent in the most dependent 
parts, which are usually the lower part of the trunk of the body and lower 
extremities. Later the legs become so full as to give the skin a very 
tense and shining appearance, and in the advanced stages frequently 
cause bullae or blisters to make their appearance, followed by superfi- 
cial ulcerations and the dripping of serum, sufficient to keep the clothes 
of the patient and the bed upon which he lies constantly wet. The 
more fully the tissues of the body are infiltrated with the serum the 
more scanty as a rule the urine becomes till in the advanced stages the 
amount passed each day is very small, when the symptoms usually take 
one of three directions. In at least one third of the cases after the patient 
arrives at this stage the elimination of urea and excretory elements of 
urine become so small that the accumulation of these materials in the 
blood begin to display their toxic effect upon the nervous centers and 
cause, first, muscular twitchings, more decided headache, dimness of vision, 
sometimes dullness of hearing, and finally general convulsions, dilatation 
of the pupils of the eyes, coma and death. Perhaps one third of all the 
cases of chronic interstitial nephritis, or chronic Bright's disease, as it is 
more frequently called, terminate fatally through uraemie po : soning. Death 
does not occur always by action upon the brain, however, for in some in- 
stances instead of producing the nervous symptoms followed by convulsions 
and coma, which I have described, violent vomiting and purging takes 
the place of the convulsions, producing exhaustion almost as rapidly as 
an attack of cholera. In some of these instances after the patient has 
been much reduced by the copious evacuations, enough of the urea and 
elements of a toxic character are carried away with the evacuations from 
the mucous membranes to relieve the patient temporarily, and he is 
restored to a better condition than before the attack. The improvement, 
however, lasts only for one, two or three weeks, when a repetition of the 
same symptoms may take place exhausting the patient still further, and 
sometimes ending in fatal collapse. Another mode by which a con- 
siderable proportion of these cases terminate after the dropsical effusions 
have come to pervade the tissues of the body generally, and the urine has 
become very scanty, is by the supervention of local inflammations; particu- 
larly the sudden occurrence of peritonitis, pleuritis or pericarditis, followed 
by copious effusion into these respective cavities. Perhaps the pleura is 
more frequently attacked than any other of the serous membranes. From 
the supervention of acute inflammation in any of these serous surfaces the 
patient becomes rapidly prostrated; the amount of effusion into the cavity 
usually so far embarrassing the respiratory and digestive functions as to 
soon terminate life. In another class of cases without the supervention of 
any noticeable inflammation, after the general areolar tissues of the body 
have become thoroughly infiltrated with serous fluid, effusion begins to 
take place into the serous sacs, and sometimes into the pulmonary tissue, 
causing hydro-thorax, ascites, sometimes hydrops pericardii, and frequently 
pulmonary oedema. The latter usually speedily terminates fatally from 
interference with the oxygenation and decarbonization of the blood. In 
addition to the symptoms which I have detailed in giving the clinical 



ANATOMICAL CHANGES. G23 

history of these cases, from the early stage to the end, it is proper to men- 
tion, as of not infrequent occurrence during the more protracted cases, and 
ospviillv in thosa which are associated with a considerable degree of 
dyspnoea from time to time, hypertrophy of the heart, which adds to the 
tendency to congestion both in the lungs and in the brain. Another 
very important item connected with the symptoms of these cases is the 
condition of the urine. From the earliest period in their progress this 
secretion is found to contain more or less albumen. This is readily made 
manifest by the ordinary tests of heat and nitric acid. The amount of 
albumen varies much. In some instances it will be so small through all 
the early stage of the disease as to cause a mere white cloudiness in the 
test tube on the application of heat and nitric acid. But when the dis- 
ease is further advanced the amount of albumen becomes larger, and in 
many instances will equal one third or one half of the whole bulk of the 
urine as it settles in the test tube. Usually about in the same proportion 
as the albumen increases, the natural excretory elements of the urine, 
urea, etc., diminish in their relative proportion. Upon examination 
under the microscope the urine presents, in nearly all these cases, cells 
of renal epithelium, together with hyaline casts, fibrinous shreds and tubu- 
lar casts, which are fibrinous material molded in the shape of the urin- 
iferous tubules. In the midde and advanced stages of the disease these 
tubular casts will almost always be more or less dotted over with fat 
granules. 

The three most important items connected with the symptomatology of 
this form of renal disease, are the appearance of albumen, epithelium and 
tubuiar casts in the urine; the supervention of dropsical infiltration, 
always commencing in the areolar tissue, but influenced much by gravity 
as to its location; and the retention of urea and effete elements of urine in 
the blood as indicated by their effects upon the nervous centers and mu- 
cous membranes. The tendency of all these cases when thoroughly es- 
tablished, is towards a fatal termination; yet progressing with a very vari- 
able degree of rapidity, sometimes there will be intervals of considerable 
duration in which the symptoms of the disease remain stationary, or im- 
prove. This condition excites in the patient more or less the expectation 
of recovery. Nevertheless it ultimately proves temporary, and is followed 
by a return of all the more prominent and active symptoms of the disease. 
Another complication that occasionally makes its appearance in connec- 
tion with Bright's disease, sometimes early in its progress, but more fre- 
quently in the middle and latter stages of advancement, is amaurosis, or 
loss of vision. This occurrence is caused by a retenitis resulting quickly 
in the formation of white or yellowish stellated spots in the retina, with a 
considerably increased size of the blood vessels. The stellated spots are 
regarded as the result of fatty degeneration of the structures. 

Anatomical Changes. — Chronic albuminuria or diffuse chronic nephritis 
when terminating fatally, leaves the kidney, on post-mortem examination 
in one of the three following conditions: In the first condition the kidney 
is enlarged, whiter or paler than natural, less dense in texture; the capsule 
is easily detached. When the organ is laid open and examined minutely, 
the coats of the smaller arteries are usually found hypertrophied, or thick- 
ened, the tubules more or less full and obstructed with tubular casts, evi- 
dences of fatty degeneration throughout a large part of the cortical texture, 
the glomeruli surrounded, many of them, by fibrinous exudation intermin- 
gled with fat granules, and generally so altered as to allow of a very free pas- 
sage of the serum of the blood directly into the urinary tubules. In the 
second variety the appearances are very similar in all respects to that just 



624 CHROXIC NEPHRITIS. 

described, with the exception that the cortical portion of the kidney has 
undergone more of a degenerative change either of a fatty, or amyla- 
ceous character. The latter is shown by the characteristic blue tint on the 
application of iodine, and produces what is usually called the waxy or 
amylaceous kidney. The third variety presents the typical condition of 
the kidneys, originally described by Dr. Bright, and to which was origi- 
nally applied the name of Bright's disease. This change consists in the 
contraction of the kidnej^s, causing them to be diminished in size, of a 
deeper red color, frequently mottled a little upon the exterior, and some- 
times showing numerous small, gray, granular specks, or deposits beneath 
the capsule. When laid open the cut surface presents a red granular ap- 
pearance, denser than natural, the connective tissue throughout being some- 
what hypertrophied. The thickening and hardening of this structure 
with much fibrinous, fatty and granular material occupying the interstitial 
spaces in the cortical structure surrounding the glomeruli and malpighian 
tufts make the condition somewhat analogous to sclerosis, more frequent- 
ly described as cirrhosis of the liver. Some writers have claimed 
that these different appearances of the kidney indicate only different 
stages in the progress of one and the same disease. This, however, is not 
probable; if it were there would be some uniformity in finding one variety 
of these appearances in cases that had died early, another variety later, 
and another still later; but post-mortem examinations connected with the 
history of cases, do not present any such uniformity or coincidence of one 
variety of appearances with any particular duration of the disease. And 
while they are all consequences of some inflammatory action pervading 
the connective tissue and vascular structure of the kidney their variation 
does not depend upon the duration or stage of progress so much as it 
does upon the particular influences, or combination of influences, that 
have determined the development of the disease, or exerted more or less 
modifying influence upon its progress. 

Diagnosis. — Perhaps the only reliable diagnostic symptoms, or signs of 
the existence of chronic nephritis are the presence of more or less albumen, 
coincident with renal epithelium and tubular casts in the urine, taken in 
direct connection with the preceding gradual failure of strength, pallor of 
countenance, and more or less of dropsical appearances in the areolar 
tissue and dependent parts of the body, or of the extremities. The simple 
appearance of albumen alone in the urine is by no mlkns evidence of 
chronic nephritis, or any structural change of the kidney. As we have 
had occasion to point out, when speaking of the different forms of hyper- 
aemia and simple congestion of the kidneys, albumen is of common occur- 
rence in all those conditions in which the capillary vessels of the kidney 
become more or less overcrowded with blood; whether from active deter- 
mination of blood to the part, or mere passive accumulations from defect- 
ive vasomotor influence over the circulation. But when the symptoms 
of failure in the patient have been gradual, presenting progressively 
increasing paleness, puffiness of the features, and the albumen becomes 
a constant element in the urine, associated directly with more or less of the 
tubular casts and epithelium, there can be little, if any, doubt, about the 
existence of chronic interstitial, or diffuse nephritis. The practitioner, how- 
ever, should never be satisfied with the examination of a single specimen 
of urine. It is better that the specimen to be examined be taken from the 
urine passed in the morning before the patient has taken food, and then at 
least two or three specimens be examined at intervals of three or four days. 

If, with the general symptoms that I have indicated such examinations 
show the materials in the urine that I have mentioned, there need be no 



PROGNOSIS. 625 

doubt or hesitation in pronouncing positively in regard to the diagno- 
sis. It is true, there are many cases so plain that a single examination, 
in connection with the symptoms, is sufficient to remove all doubt; but 
this is not generally the case in the earlier stages of the disease. 

Prognosis. — Some writers represent the prognosis in chronic nephritis 
as uniformly unfavorable; the disease in their estimation uniformly ter- 
minating ultimately in the death of the patient. My own experience has 
led me to differ from these conclusions, so far as to regard a considerable 
number of cases that present all the symptoms that are regarded as neces 
sary to constitute proof of chronic nephritis, as capable of terminating 
in recovery. I know of no instance of recovery, however, if the disease 
has existed for a considerable period of time before being brought under 
judicious treatment; and it is proper to add that the great majority of 
cases, whether treated early or late, and in the most skillful hands, will 
eventually reach a fatal result. The cases which have come under my 
observation, and ultimately terminated favorably, originated during the 
convalescent stage of the eruptive, or some one of the general fevers. In 
one instance a case came under my care in the hospital, which had super- 
vened during the convalescence of the patient from typhoid fever, and 
after the disease had existed for six or seven months recovery took place. 
In another instance a young man, in whom the disease appeared to origi- 
nate from long continued exposure to cold and damp in illy ventilated 
apartments, recovered after the disease had continued between five and 
six months. I have seen a considerable number of cases following scarlet 
fever, in which the disease supervened so gradually, with so little active 
symptoms as to indicate certainly no more active grade of inflammatory 
action than what would be properly called chronic, in which recovery has 
taken place after the disease had continued from six to ten weeks. But 
in nearly all the cases in which the real disease has resulted from intem- 
perate habits or the habitual use of alcoholic beverages, or in connection 
with constitutional syphilis, or with well marked gouty or scrofulous dia- 
thesis, they have proceeded with much uniformity to a fatal result. 

Treatment. — In the treatment of all cases of chronic interstitial or dif- 
fuse nephritis, the practitioner should have three objects constantly in 
view, namely, the arrest of the inflammatory process itself by lessening 
the vascular fullness and irritability of the structure of the kidney; the 
prevention of the accumulation in the blood of the excretory elements of 
the urine, thereby avoiding, or postponing as far as possible, the toxic 
effects of these agents upon the blood, and especially upon the nervous 
centers; and the palliation or removal of the dropsical accumulations and 
other complications liable to arise in the progress of the case. For the 
accomplishment of the first of these objects, the due regulation of the 
diet, drinks and general hygienic management of the patient is of great 
importance. All alcoholic beverages, both fermented and distilled, should 
be rigidly excluded from the patient's use; the diet should consist largely 
of milk and farinaceous articles, with a limited amount of vegetables and 
fruit, while meat should be used rather sparingly. As a drink perhaps no 
article is better than either buttermilk or milk whey. Some mineral 
waters have been recommended, and in the early stage of the disease 
I have thought some advantage was derived from having the patient 
use as freely as convenient such mineral waters as are represented by the 
Bethesda springs, at Waukesha, in Wisconsin. The patient's clothing 
should be such as to protect the surface as much as possible from sudden 
atmospheric impressions, especially cold and damp. Flannel worn next 
to the skin is best for this purpose, and should be continued throughout 
40 



626 CHRONIC NEPHRITIS. 

the year. Many patients also derive advantage from a warm alkaline 
bath, at least twice a week, as warm as can be borne comfortably, with a 
view of producing exhalation from the cutaneous surface, as well as acting 
derivatively upon the circulation in the kidneys. The exercise of the 
patient should be limited; avoiding all attempts at active muscular exer- 
cise, sufficient to produce weariness. Frequent riding in the open air, 
especially in clear weather, is well calculated to maintain appetite aud 
promote the general health of the patient. In addition to these hygienic 
measures I have certainly seen patients derive much benefit, especially 
during the earlier stages in the progress of the disease, from the use of 
the following formula: 



Potassii Nitratis 


15 grams 


3iv 


Extract! Galii Fluidi 


75 c. c. 


?iiss 


Extracti UvaeUrsi Fluidi 


75 " 


giiss 


Extracti Ergotae Fluidi 


30 « 


P 



Mix. Of this I have usually given four cubic centimeters (fl. 3i), mixed 
with half a wine glass full of sweetened water from three to four times a day. 
In other instances, more especially those in which the bowels are inclined 
to costiveness, I have derived some benefit from the use of an infusion of 
digitalis ieaves, holding in solution the bitartrate of potash, given in such 
doses as the patient will bear without inducing too much effect from the 
digitalis upon the circulation on the one hand, and without causing ex- 
cessive looseness of the bowels by the bitartrate upon the other. Most 
patients will bear profitably six to eight cubic centimeters (fl. 3'ss to 3ii) of 
an infusion, made by placing eight grams (3ii) of the bitartrate of potas- 
sium and the same amount of digitalis leaves in two hundred and sixty 
centimeters (fviii) of boiling water, three or four times a day. Both of 
these formulae that I have given, have a tendency to increase the elim- 
ination of the watery elements of the urine, while they improve the vaso- 
motor influence over the smaller blood vessels and thereby lessen the 
hyperaemia or congested condition of these vessels in the kidney. Either 
of the prescriptions may be rendered somewhat anodyne by adding to 
them a due proportion either of the conium or hyosciamus. If the 
patient is already showing considerable evidence of anaemia, it will in 
most instances produce a most beneficial effect, to give from ten to twenty 
minims of the tincture of the chloride of iron, largely diluted with water, 
after each meal time. Many recommend also the use of astringents, more 
particularly tannic, gallic acid, and other vegetable astringents, with a view 
of lessening, by their action upon the vessels of the kidneys, the excretion 
of albumen. I have seen many patients to whom this class of rem- 
edies have been administered in considerable variety, but I have 
never known any beneficial results from their use. There is a pretty 
uniform expression on the part of the writers and teachers in oppo- 
sition to the use of mercurials in all stages of chronic nephritis. Pre- 
cisely on what grounds this interdiction rests is seldom stated, and is not 
very apparent from anything connected with the pathology of the disease. 
And while I can see no indication for the use of calomel and blue 
mass, particularly, either for cathartic purposes or for active alterative 
influences, I must state as a clinical fact, that I have seen in a con- 
siderable number of cases of well marked chronic nephritis, often of con- 
siderable duration, very much improvement follow the use of small doses 
of the bichloride of mercury in connection with tonics and a proper reg- 
ulation of the diet. As long ago as 1848, while residing in the city of New 



TKEATMENT. 627 

York, a man in the middle period of life, affected with general dropsy, 
from chronic nephritis — the urine containing albumen, tubular casts, 
epithelium and fat granules — came under my care after he had pre- 
sented himself at one of the college clinics of Dr. Willard Parker, then 
professor of surgery in the "College of Physicians and Surgeons" of that 
city, where the case was thoroughly and critically examined and decided 
to be one of hopeless chronic diffuse nephritis, having its origin in the 
moderately intemperate habits of the patient. The dropsical effusion had 
invaded the areolar tissues throughout the whole periphery of the body. 
The case came under my care as a charity patient, and desiring to make 
the poor man as comfortable as possible, I put him upon the internal use 
of bichloride of mercury and tincture of cinchona in such proportion that 
he would get two milligrams (gr. 1-30) of the bichloride, with four 
cubic centimeters (fl. 3i) of the tincture of cinchona, diluted with sugar 
and water, four times a day. At the same time he was directed to pre- 
pare an infusion of yellow dock and sarsaparilla roots, with bitartrate of 
potassium, of which he was to take a wine glass full after each meal. 
Alcoholic drinks were rigidly prohibited, and a diet consisting mostly of 
milk, farinaceous articles and vegetables, with only a limited amount of 
meat, was allowed. Although this case had been in progress for nearly 
one year since the initial symptoms manifested themselves, and his limbs 
were so large from cedematous infiltration, that it was difficult for him to 
walk, his symptoms slowly improved under this treatment until in about 
three months he was able to go about with facility, and went out of the city 
into the suburbs, and did some work during the season of cutting hay. 
Though he did not get well he continued very much improved for more 
than twelve months after he came under my care; at which time I left the 
city and subsequently lost all track of the patient. I mention this 
because it was the first case that came under my care in which I gave the 
bichloride of mercury. Its administration was founded upon the recom- 
mendation of the same remedy in similar cases by one of the most distin- 
guished members of the staff in attendance upon the New York hospital, 
and from that period up to the present time in purely chronic cases of 
nephritis, in which there is no direct tendency to irritation of the mucous 
membrane of the alimentary canal, and the patients are not extremely 
anaemic, I have certainly seen decided benefit, sometimes amounting to 
an entire arrest of the progress of the disease for a considerable period of 
time, and in others to a more effectual retardation than was obtained by 
the use of any other one remedy. I have never pushed the remedy to 
the extent of any specific mercurial impression upon the mouth and gums, 
and I advise that in all instances of its use the effects be noted sufficiently 
to guard against any such impression or any considerable disturbance of 
intestinal discharges. But that it sometimes is decidedly beneficial I have 
had opportunities even within the last few weeks to judge in a case to which 
I was summoned at a distance in the country, where consultation was 
had almost exclusively for the purpose of deciding whether mercurials in 
this form should be used or not. And after the administration of the 
bichloride in small doses in connection with diuretics and tonics, the 
patient improved to a very unexpected degree. But I would by no means 
advise the indiscriminate use of the bichloride in chronic nephritis in any 
stage of its progress. However, I think its entire prohibition is as inju- 
dicious as the prohibition of mercurials in aiding to procure the evacuation 
of retained excretory matter in many of the cases of acute nephritis. The 
remedies which are most efficient in accomplishing the second purpose, 
namely, to prevent such a degree of accumulation of the effete constituents 



628 CHRONIC NEPHRITIS. 

of the urine as to endanger the development of toxsemic effects in the 
system, are essentially the same as have been recommended for accomplish- 
ing the first. But whenever, either from absence of any treatment or in- 
efficiency of the remedies used, the accumulations of these effete constitu- 
ents have already increased until they begin to exhibit their effects either 
upon the nervous structures or mucous membranes, then the question will 
be how best to effectually promote their elimination, at least to a sufficient 
degree to ward off the immediate danger of fatal consequences to the 
patient. Perhaps for immediate relief the administration of a sufficient 
amount of pilocarpine or of the fluid extract of jaborandi to produce free 
diaphoresis, will be valuable in many cases, and yet it is necessary to note 
carefully the degree of debility of the patient, and the danger of pro- 
ducing too much depressing effect upon the circulation by the use of this 
remedy. The bowels may also be opened freely where they are in any 
degree constipated, by such remedies as promote copious liquid discharges, 
as the bitartrate of potassium in combination with jalap, or suitable doses 
of elaterium. In addition to these and other agents that act freely in pro- 
moting eliminations through the alimentary canal, and through the skin, 
immersing the patient in a warm bath, or in a hot air bath, may also pro- 
duce some beneficial effect. But in a large proportion of the cases, after 
urea and other elements of the urine have accumulated to such an extent 
as to produce a decided impression upon the nervous centers, all remedies 
that may be used will be found to produce only temporary relief. The 
toxasmic symptoms return again and again till a fatal result supervenes. 
When in the progress of the case the continuance of the secretion of the 
natural elements of urine is sufficient to prevent uraemic poisoning, yet the 
progressive impoverishment of the blood leads to an increase of the drop- 
sical effusions, until infiltration of the tissue is so universal that not only 
the areolar tissue but the abdominal cavity becomes filled up, the urinary 
secretion extremely small, the heart's action more or less weak, and the 
descent of the diaphragm impeded, rendering respiration imperfect and 
oppressed, the blood is imperfectly decarbonized, giving the lips a blue- 
ish, leaden tint, and is accompanied by more or less coldness of the ex- 
tremities, drowsiness and yet inability to take the recumbent position, and 
to sleep on account of the feeling of suffocation. Under such circum- 
stances there is evidently imminent danger of the supervention of oedema 
of the lungs and death from apnoea, or such a degree of failure in the oxy- 
genation and decarbonization of blood as to produce general paralysis, 
coma and death from suspended cerebral function. When the patient 
progresses in this direction till the infiltration begins to crowd upon 
the chest and render the breathing more or less oppressed, and the use of 
hydragogue cathartics, diuretics, hot baths and pilocarpine have ceased to 
ward off further progress, the only resort that has been effectual in my 
hands in affording relief, has been the making of free incisions into the 
ankles; not mere punctures as directed by most writers, but one free in- 
cision in each ankle, an inch or more long, and deep enough to cut 
through all layers of fascia down to, or close to the periosteum. Make 
the incision on the inner part of the ankle, above the internal malleolus. 
An incision of this kind into each ankle will cause a very free exit of 
serous fluid. The body and limbs should be placed a little inclined, 
with oil cloth, or oil silk under the limbs in such a way as to direct 
the serum into some vessel, and thus prevent the bed-clothes from becom- 
ing wet. In most cases it will effectually drain all the tissue of the body 
in three or four days. I have practiced this in a considerable number of 
cases with entire success so far as regards the removal of the dropsical 



TREATMENT. 629 

accumulations. And in almost every instance, as soon as the water was 
fully drained from the tissues, the kidneys resumed an increased elimination 
of urine, the breathing became full and free, the blood better oxygenated, 
and the patient apparently took a new lease of life. Id two or three cases 
in which 1 had supposed that the patients were utterly hopeless, the relief 
obtained, instea I of proving temporary, becam epermanent. The serous 
fluid usually continues to drain freely through these inc : sions for several 
weeks, and if the incisions are well cared for, the limbs kept well 
washed, the margins of the incisions bathed with a little glycerine, or 
vaseline every day, it is very rare that they give the patient any trouble 
from erysipelas, or much pain from heat and smarting. But in most in- 
stances they slowly heal, and in from four to eight or ten weeks they will 
be closed up, and with the exception of three or four cases, to which I have 
just alluded, the dropsical accumulations slowly return. In cases of this 
class in which the renal disease remains and increases, and there is con- 
sequently a slow return of the dropsical accumulations, the incisions have 
afforded the patients a number of months of additional life, and I have, in 
a few instances alter they have become again thoroughly filled up, repeated 
the incisions and thus perpetuated life apparently from three to twelve 
months longer than it would have otherwise continued. I am well sat- 
isfied, however, that one reason why the secretion of the urine diminishes 
so markedly and ultimately becomes arrested so as to hasten a fatal ter- 
mination in a large proportion of these cases, is that the pressure of the 
accumulated dropsical effusion upon the renal vessels, and in some instan- 
ces more or less actual cedematous infiltration in the renal tissues, consti- 
tutes one of the causes for finally suspending the secretory action alto- 
gether. And again, whenever by any process the areolar tissues are 
drained of this fluid, and the circulation in all the capillary vessels through- 
out this kind o: structure in the body, and especially in the periph- 
ery, is restored, the pressure upon the vessels and structure of the kidney 
is relieved somewhat in the same proportion as elsewhere; and it is in con- 
sequence of this that there is so uniform an improvement in the secretion 
of the kidney, which usually lasts for a long time after the patient has 
been relieved from dropsical accumulations by this mode of tapping. 
Thorough incisions through all the tissues down to the vicinity of the 
periosteum in the ankles, with the limbs in a moderately dependent posi- 
tion, almost as certainly drain all the tissues of the body of general cedem- 
atous infiltration as the insertion of the trochar into the peritoneum 
drains the cavity of that membrane of fluids that have accumulated in it. 
In regard to the treatment of the various complications such as the super- 
vention of pleurisy, peritonitis, cardiac disease, etc., during the progress 
of marked renal trouble, I have only to remark that they are to be treated 
on the same principles as we would treat these affections under other cir- 
cumstances, making due allowance for the general condition of the 
patient. In most cases, whatever treatment is adopted, proves only palli- 
ative, or at best postpones for a brief period, the final result — death, of 
the patient. 



630 SUPPURATIVE NEPHRITIS. 



LECTURE LIX. 



Suppurative Nephritis— Its Causes, Symptoms, Anatomical Changes, Diagnosis, Prognosis, and 
Treatment. 

GENTLEMEN: Under the head of Suppurative Nephritis may be in- 
cluded several affections of the kidneys, differing in their etiology 
and clinical history, but all accompanied by the formation of pus<in the 
parenchyma of those organs. The causes which lead to suppuration or "to 
the accumulation of pus in the kidneys are various, and the accumulations 
consequently present several distinct forms. All those conditions of the 
blood, usually included under the heads of pyaemia and septicaemia are 
liable to be accompanied by suppurative inflammation or purulent depos- 
its in the kidneys. In this class of cases the pus is usually collected in 
small but numerous abscesses, varying in size from a pin's head to that of 
a pea, or several of these small abscesses may be united together forming 
a larger one the size of a hickory nut. Examination of the kidney in this 
class of cases shows usually several stages in the progress of this form of 
disease. In the beginning, the inflammatory process will cause the ap- 
pearance of white, or yellow spots, which, when examined more closely 
with the aid of the microscope, will be found to consist of small portions 
of the renal substance affected with necrosis or death of the cell structure, 
with generally more or less pus globules recognizable, and in the midst 
of them a group of bacterial germs. By most writers of the present day, 
it is supposed that the lodgment of these bacteria from the blood, consti- 
tutes the commencement of the disease in the kidney, and that they are 
the special cause inducing inflammation, necrosis or death of the immedi- 
ately surrounding tissue and subsequent degeneration into pus. In 
most cases the same kidney will present all the different stages of 
progress, from the simple accumulation of groups of bacteria with 
the first appreciable change or impairment of the tissue in contact with 
them in some places, more decided death or necrosis of the tissue with 
pus cells diffused in it in others, and still further, places where the puru- 
lent degeneration is more complete, and distinct abscesses have attained a 
size easily recognizable without magnifying power. In almost all cases 
arising from pyasmic and septicemic conditions the renal disease is as I 
have just described, and results in the formation of numerous small ab- 
scesses. There is another class of cases which originate not from general 
septicaemia, but from inflammation previously existing in other parts of 
the urinary organs, or in the parts within the pelvis. They occur so fre- 
quently in connection with pelvic inflammations after surgical opera- 
tions upon the urinary organs, that they have been called surgical kid- 
neys. In such the evidences of inflammation in the parenchyma of the 
kidney is more general; the suppuration takes place more rapidly and 
ends in the formation of one or more abscesses. Sometimes, indeed, the 
suppurative processes resulting from previous abscesses and ulcerations in 
connection with the pelvis or urinary organs, rapidly disorganizes the 
whole substance of the kidney and ultimately converts it into a purulent 
mass. And sometimes the suppurative inflammation invades the areolar 
tissue exterior to the kidney constituting a peri-nephritic suppuration. 
Perhaps this form of destructive suppurative inflammation in the paren- 
chyma of the kidney is more liable to follow primary abscesses in the pros- 
tate gland than in any other part connected with the urinary organs. 



SYMPTOMS. G31 

Next in frequency is their occurrence after operations for the removal of 
urinary calculi from the bladder. Another class of cases in some 
measure intermediate between those connected with pyaemia or septicaemia 
and the more generally rapid suppurative conditions of the kidney result- 
ing from injuries or surgical operations and abscesses in other portions 
of the urinary apparatus to which I have alluded, arise mostly from, or in 
connection with, suppurative pericarditis, or the formation of continuous 
suppurative processes in the lungs. Suppurative pericarditis itself is not 
a very frequent affection; but in the larger proportion of the cases that 
have occurred in which examinations have been made, secondary abscesses 
have been found in the kidneys sometimes in one, but more frequently in 
both. There is some liability to the formation of these nephritic abscesses 
during the progress of any long continued internal suppurative process, in 
almost any part of the body. In very many of the cases of suppurative ne- 
phritis resulting in the formation of abscesses, whether large or small, there 
is also coincident inflammation in the lining of the pelvis of the kidney, 
accompanied by the establishment of suppurative processes exterior to 
the inflamed organs. Tnis is what constitutes a peri-nephritic inflam- 
mation, or peri-nephritis. In other instances the inflammation is limited 
to the lining of the pelvis of the kidney, and does not extend to the paren- 
chvma of the secreting structure. Such cases are denominated pyelitis. 
And those cases of pyelitis uncomplicated by extension of inflammation 
to the parenchyma of the kidney, may originate simply from extension of 
inflammation from the bladder, through the ureters to the pelvis of the 
kidney, as I have seen in several instances of chronic cystitis. More fre« 
quently, however, the pyelitic inflammation has either resulted from 
ordinary causes, such as exposure to cold and damp, which is followed in a 
short time by suppuration in the inflamed membrane ; or far more 
frequently, pyelitis originates from the formation of urinary calculi in 
the pelvis of the kidney, or in the infundibular spaces. The formation of 
nephritic calculi almost always, sooner or later, gives rise to the establish- 
ment of chronic suppurative inflammation in the whole lining membrane 
of the pelvis of those organs, and not infrequently causes also an obstruc- 
tion of the ureter by the lodgment of calculi in it, whereby both the 
urine and muco-purulent material resulting from pyelitic inflammation is 
prevented from passing into the bladder, and escaping through the ure- 
thra, and its retention causes distension of the pelvis first, and subsequent- 
ly more or less of the ureters, generally giving rise to a swelling suffi- 
cient to be easily detected by examination through the abdominal parie- 
tes, and distinguished from other tumors. 

Symptoms. — There are no local symptoms that usually accompany the 
formation of pus in those cases of suppurative nephritis arising from sep- 
ticaemia, or pyaemia, and the existence of such condition of the kidney is 
only detected by post-mortem examination. The patients of this class 
are always laboring under the general symptoms of pyaemia or septicae- 
mia, and the establishment of the colonies of bacteria, as the nuclei of 
numerous small abscesses or collections of pus gives rise to no pains that 
attract attention from the more general symptoms, nor do they usually so 
far interfere with the secretion of urine, as to arrest the elimination of 
urea, and cause the retention of the elements of urine sufficient to pro- 
duce uraemic poisoning. In some instances where that change in the 
structure of the kidney is very extensive, there may be a decided dimi- 
nution in the quantity of the urine, and a sudden development either of 
convulsions, or the supervention of coma and death. But in the great 



632 SUPPURATIVE NEPHRITIS. 

majority of instances of this class the result depends not upon the renal 
disease, but upon the general coincident condition of the system, of 
which the renal difficulty is only a secondary development. Should the 
general disease be controlled, and the formations of pus in the kidney be 
limited to the condition of very minute abscesses, in which the pus is sup- 
posed to be capable of undergoing a species of caseous degeneration and 
partial removal, there is a possibility of the recovery of the patient with- 
out permanent impairment of the function of the kidney. In those cases 
of suppurative inflammation of the kidney depending upon, or secondary 
to, surgical operations, or primary abscesses in the prostate gland, or in 
other parts within the pelvis, the lung, or in the course of the urinary pas- 
sages, there are local symptoms which are more or less distinctive of the 
renal affection. The patient usually begins to complain of dull, aching, 
persistent pains in the loins, often extending into the hips and sacrum, ac- 
companied by dry skin, increased frequency of pulse, increased temper- 
ature, especially in the afternoon and evening, with sufficient diminution 
to constitute a perceptible remission in the morning. There is much 
restlessness on the part of the patient, scantiness of urine, frequently 
causing heat and burning on passing it, and in from two to five days 
there usually occur decided chills, followed by brief paroxysms of high 
fever and copious sweating. On the supervention of the chills and sweats 
the pulse becomes smaller and more frequent, the temperature, especially 
during the afternoon and evening, rises higher, when the patient be- 
comes more or less incoherent or troubled with dreams. The urinary 
secretion may be small or it may be nearly natural in quantity, but it 
becomes now mixed with pus, which gives it a slightly turoid appearance 
when it is passed, but on allowing it to stand falls as a layer of whitish 
matter at the bottom of the vessel. Microscopic examination shows it to 
be made up almost entirely of pus mingled with some renal epithelial 
cells, and sometimes red corpuscles of blood. The patient rapidly loses 
flesh and strength, and in some instances the proportion of urea in the 
urine is very much diminished. In such cases the stomach becomes ex- 
cessively irritable, causing the prompt rejection of everything that is 
taken upon it, whether food, drink or medicine. The progress of such 
cases from this time on is very variable, as regards duration. In some 
instances which have come under my observation, the patients presented 
daily the phenomena of the regular hectic type of general fever, with 
progressive emaciation and total inability to retain anything upon the 
stomach, much of what was taken regurgitating without the act of vomit- 
ing. The intestines remaining entirely empty, become contracted, while 
the urine is constantly impregnated with a considerable quantity of 
pus, and death takes place from simple asthenia, at the end of from three 
weeks to three months. In other instances, however, as the disease pro- 
gresses the destruction of the renal tissue becomes so great as to prevent 
the elimination of the natural effete elements of urine and their retention 
in the blood causes toxic effects upon the brain and nervous centers, 
bringing on the usual muscular twitchings, more or less convulsive move- 
ments, coma and death. Such cases usually progress much slower than 
those I have just previously mentioned. In addition to the symptoms 
that I have already mentioned in the cases of more general suppurative 
inflammation, the kidney, usually, after the first three or four days, be- 
comes enlarged sufficient to be detected by examination, and sometimas 
it attains a size sufficient to present a distinct tumor, which can be easily 
included between the fingers of one hand placed underneath the eleventh 
or twelfth ribs posteriorly, and those of the other placed directly under 



symptoms. : 633 

the margin of the ribs opposite the angle of the colon on either side anterior* 
ly. The shape of the tumor thus included between the two hands may be 
traced sufficiently to clearly indicate its origin as distinguished from that 
of enlargement of the spleen or any accumulations within the angles or 
sigmoid flexure of the colon. The formation of such a tumor or swelling 
accompanied by a greater or less amount of pus intimately intermixed 
with the urine as it is passed, separating when the urine is allowed to 
stand, is sufficiently diagnostic of suppurative renal disease. When the 
inflammation and suppuration occur exterior to the kidney as in peri- 
nephritic suppuration, the general course of the symptoms is very nearly 
the same, and may present more or less of a tumor locally, but it will dif- 
fer in the fact that there will be little or no appearance of pus in the urine 
unless there be coincident suppuration in the kidney at the same time, 
as sometimes happens. In a case that came under my own observation 
not very long since, in which all the symptoms of suppurative nephritis of 
an acute and severe character were present, the post-mortem revealed the 
fact, not only that the parenchyma of the kidney in the left side was 
almost entirely disorganized, and converted into pus, but a considerable 
collection of pus also existed exterior to the kidney constituting an abscess 
between it and the lumbar muscles. In this same case there were one or 
two small collections of pus in the parenchyma of the opposite kidney. 
The primary disease was dependent on inflammation and suppuration in the 
prostate arising from a contusion in the perinaeum. When the suppura- 
tive inflammation attacks simply the mucous membrane lining the pelvis 
of the kidney constituting pyelitis, the general symptoms are less severe. 
Indeed, there is generally little or no febrile disturbance or increased 
temperature, and but little acceleration of the pulse, but there is in most 
instances dull, aching pains in the loins, generally increased by standing 
or walking, some degree of tenderness to pressure underneath the margin 
of the ribs in the lumbar and lateral spaces in the direction of the kid- 
neys. And after the disease has advanced a short time there is more or 
less distension of the pelvis of the kidneys which may be felt as a tumor 
or swelling projecting below the margin of the ribs, or between the mar- 
gin and the anterior crest of the ilium, coincident with decided increased 
fullness or tumefaction posteriorly in the lumbar region. Pyelitis exist- 
ing alone without involving the structure of the kidney is manifest, how- 
ever, more by the condition of the urine, than by either general or local 
symptoms. In nearly all such cases the urine, though showing but little 
alteration from its natural appearance when voided, yet when allowed to 
stand will generally deposit more or less mucus in the early stage, subse- 
quently muco-purulent material, and in the later stages much pure pus. 
When the pelvis of one kidney is affected there will be frequently days 
and parts of days when the urine that is voided will appear perfectly nat- 
ural, neither depositing muco-purulent material nor exhibiting any devia- 
tion from the natural condition. And if attention is given closely to the 
patient it will be found that at such times the tumefaction and swelling 
on the affected side has steadily increased, and is usually accompanied by 
increased heaviness or weight and dull pain in the lumbar and iliac regions, 
and in one or two days, sometimes three, the urine will become suddenly 
more copious, looking a little turbid when passed, and depositing, on 
standing, large quantities of pus and muco-purulent material with dimi- 
nution in the fullness of the side, and more or less relief to the dull pain 
and sense of weight that had previously existed. The explanation of this 
occurrence is, that in pyelitis, the thicker portions of the pus and 
muco-purulent material are liable to lodge in the ureters and pro- 



634 SUPPURATIVE NEPHRITIS. 

dace temporary obstructions to the passage of urine, or of the products 
of the inflammation, causing them to accumulate till the pelvis is more 
distended, giving rise to a greater amount of fullness, weight, and dull 
pain, and as the urine is entirely obstructed from the diseased part, the 
patient voids only the urine from the healthy kidney, and consequently it 
presents the natural color and appearance, at the same time that the 
symptoms of trouble upon the other side in all other respects are aggravat- 
ed. As the pressure accumulates, the obstruction in the ureter is forced 
through into the bladder, allowing again a discharge of the contents of the 
pelvis, consequent lessening of the tumefaction, and more or less relief to 
the pain, while the urine coincidently becomes very much impregnated 
with inflammatory products consisting of mucus, pus and not infrequent- 
ly red blood corpuscles. When pyelitis originates from causes not in- 
volving the formation of urinary calculi, there may be at no stage in its 
progress, red blood corpuscles in the urine but only mucus and pus; and 
these will vary much in their relative proportions as well as in their abso- 
lute quantity. But when the pyelitis has been caused by the prior for- 
mation of renal calculi, there are very few instances in which there is not 
at times hemorrhage sufficient to make blood quite manifest in the urine 
when voided. There are some cases, however, of this variety in which the 
calculi are numerous, varying much in their size, one or more of them too 
large to engage in the ureters at all, but being retained in the pelvis of 
the kidney, others of such size that they actually engage in the ureters 
and pass through it, producing during the passage more or less severe 
pain, sometimes excruciatingly severe, which ceases abruptly as soon as 
the calculus passes from the ureter into the bladder constituting what 
has been described as nephritic colic. At other times the calculus after 
passing into the ureter becomes arrested at some stage of its progress, 
is retained there, constituting a permanent obstruction to the flow of the 
urine through that duct into the bladder. These cases of accumulation 
of urine aud purulent material in the pelvis of the kidney and in the 
ureter often distend both so that the ureter itself above the point of 
obstruction becomes dilated into a sac presenting all the outlines of a 
tumor of considerable size in that part of the abdomen. When the calculi 
thus become permanently lodged in any part of the ureter from its renal 
extremity to its entrance into the bladder the resulting enlargements may 
be very various. 

In some instances it will be limited almost entirely to dilatation of the 
urethra itself, which becomes dilated into a sac sometimes two or three 
inches in diameter, while the pelvis of the kidney remains but little dis- 
tended. A case of this kind came under my observation in the capacity 
of consulting physician some years since, in which an obscure urinary af- 
fection had existed a long time, and a tumor had formed directly in the 
course of the ureter of the right side. The tumor was of an oblong form 
commencing low enough to make it difficult to get at its lower extremity 
with the ends of the fingers between it and the ramus of the pubes; while 
the upper portion could be easily outlined with the fingers, showing an 
enlargement about three or four inches in length and at least two inches 
in diameter at its largest part. This oblong tumor lying in the right side 
of the abdomen directly in the course of the ureter, and equally in the 
region of the ascending colon led his attending physician into much doubt 
in regard to the nature of the disease. The case ultimately terminated 
fatally, and in the post-mortem examination it was found that a renal 
calculus had become permanently arrested in the ureter, within one inch 
and a half of the opening of that tube into the bladder, and had appar- 



DIAGNOSIS. 635 

ently produced complete obstruction to the passage of urine and all other 
matters through that duct. This obstruction had resulted in dilatation of 
the ureter into a sac or tumor of the dimensions I have mentioned, in the 
right side of the abdomen. The pelvis of the kidney was somewhat 
dilated and contained several other additional calculi, the largest of 
which was the size of a hickory nut. Mostof these casas belong directly 
within the domain of surgery, and we need not pursue them further than 
to give you a general outline of their progress and such symptoms as will 
enable you to diagnosticate them from other forms of disease. As I have 
already stated, pyelitis may occur arid continue an indefinite period of 
time, as a chronic suppurative affection of the lining of the pelvis of the 
kidney, without involving other parts. In very many cases of pyelitis, 
there is coincident cystitis. Inflammation in both pelvis and bladder 
arises from the same causes, and leads to very similar results. 

Anatomical Changes. — I have already spoken of the anatomical changes 
which take place in the pyemic collections of pus in the kidney, where 
the purulent formations are the result apparently of colonies of bacteria 
deposited in the progress of general pyaemic or septicaemic conditions of 
the blood. Whether the bacteria are the real cause of the inflammation 
and suppuration here, or whether they are only coincident, it is not easy to 
determine. The prevalent opinion is that they are the special cause of 
the rapid degeneration of tissue, and the formation of small multiple ab- 
scesses. In the suppuration which takes places in the kidney in the prog- 
ress of suppurative pericarditis, abscesses in the lungs, or extensive 
suppurative conditions in other portions of the system, it is probable that the 
renal affection originates directly from the passage through the blood of the 
emboli, or particles of matter detached from the suppurative surfaces just 
named, and their lodgment in the minuter vessels of the cortical texture of 
the kidney. Such emboli plug up the renal vessels, and create irritation, 
which leads to rapidly suppurative inflammation, and consequent formation 
of pus. This may be confined to a limited space resulting in a single abscess, 
or there may be many points of obstruction and suppuration, and in their 
development they may unite more or less together, until a large portion 
of the renal substance becomes converted into pus. In most cases where 
examinations have been made with care, the embolic obstructions that occur 
in this class, contain also, more or less of colonies of bacteria or inicroco3ci, 
which probably bear the same relation to the suppurative processes here, 
that those connected with the septicemic cases to which I have previouslv 
alluded, bear to them. It is proper to state, that in the embolic depos- 
its not infrequently, some degree of extravasation of blood or minute 
hemorrhagic exudations take place, in the early part of all obstructions; 
and these may sometimes be detected on examination, in the places that 
have undergone the least change, while in others where suppuration is 
more complete and extensive, these hemorrhagic exudations are un- 
noticeable. 

Diagnosis. — As I have already remarked there are no symptoms notice- 
able during the lifetime of the patient by which a diagnosis of the 
cases connected with pyaemia can be made, or at least a large propor- 
tion of them ; while in other cases to which I have alluded, the more 
extensive formation of pus causes early impregnation of the urine 
with purulent material. In these, the diagnosis can almost always 
be made by noticing, first, the occurrence of pain and heaviness in 
the region of one or both kidneys, followed by more or less irregular 
chills and sweats, with the formation of a tumor consisting of the enlargi- 
ment of one or both kidneys, and the appearance of pus in the urine, 



636 SUPPURATIVE NEPHRITIS. 

when examined under the microscope. The coincidence of these circum- 
stances render the diagnosis of this class of cases sufficiently certain. 
There are some cases of pyelitis in which there is more difficulty in arriv- 
ing at a certain diagnosis between pyelitic disease and cystitis. You must 
recollect, however, that in cystitis the muco-purulent material is always 
less intimately intermixed with the urine as it is voided, and that 
there is an inclination to void the urine much more frequently than natural 
with correspondingly less at a time, and micturition is accompanied by more 
or less burning, smarting pain, and some degree of pressure: — whereas, in 
pyelitis uncomplicated by cystitis, the patient generally voids urine not 
more frequently than in the natural condition, and in thus voiding it, the 
muco-purulent material is so intimately intermixed with the urine as to give 
it a more clouded appearance but is not recognizable as a separate material 
by the eye, until it has been allowed to stand usually for an hour or more. 
There is also in uncomplicated pyelitis, absence of the sharp, smarting 
pain in voiding the urine, and of the sensation of irritation in the urethra 
or neck of the bladder. If there are exceptions to this it is when the 
pyelitis is accompanied by urinary calculi, and some of the smaller calculi 
occasionally passing into the bladder may give rise, before they pass out 
through the urethra, to sufficient irritation to cause pains similar to those 
of cystitis. But if such pains occur from that cause they will occur only 
occasionally, while in the intermediate time urine passes without burning, 
and without frequency, and yet contains an abundance of pus. Such 
cases seldom exist for a length of time without developing more or less 
enlargement of the pelvis of the kidney and consequently a perceptible 
tumor in that region which serves to render the diagnosis also more com- 
plete. Many have claimed that there is a difference in the appearance 
of the epithelium derived from the pelvis of the kidney, when in a state 
of chronic inflammation, from that detached from the surface of the blad- 
der in cystitis. It is quite evident, however, that there is not such a de- 
gree of real difference in these cases as to be of any value in diagnosis. 
But as I have previously remarked, cystitis and pyelitis frequently exist 
coincidently, when the symptoms, phenomena, and consequences of both 
are present at the same time. In such cases there will be an intermin- 
gling of the symptoms of both, and unless the pelvis of the kidney is en- 
larged sufficiently to present a recogtvzable tumefaction to aid you, it 
may be impossible to decide positively whether you have a case of cysti- 
tis alone or of cystitis and pyelitis together. Practically, however, it is 
unimportant. 

Prognosis. — The prognosis in all cases of suppurative inflammation in 
the parenchyma of the kidney must be regarded as more or less unfavor- 
able. For while it is true that a few instances are on record in which 
peri-nephritic suppuration has taken place, and by freely opening the 
abscess from behind the peritoneum and establishing drainage, patients 
have recovered; and in very rare instances when the suppuration has ex- 
isted in the substance of the kidney and a discharge of pus has taken place 
with sufficient freedom into the pelvis and through the urinary passages 
with the urine to drain the abscess and lead to ultimate recovery, or an incis- 
ion carried in the same manner as for peri-nephritic abscess boldly into the 
kidney itself, has resulted in the drainage of the abscess through the ex- 
terior with favorable results; yet these are rare exceptions when com- 
pared with the general rule, which is, that these suppurative conditions 
of the kidney ail end the life of the patients. If it be practicable, as I 
have before suggested, that those numerous points of suppuration which 
take place in the kidneys during septicemic and pyemic conditions of the 



TREATMENT. 637 

system should undergo such changes as to ultimately allow repair of the 
structure of the kidney and avoid death from renal degeneration, yet the 
great majority of patients of that class actually die from the general 
disease before such reparation has had time to take place in the kidney. 
Treatment. — But few words are necessary in regard to the medical 
treatment of all these different varieties of suppurative disease of the kid- 
ney. Those which originate in connection with pyaemia and septicae- 
mia are to be treated entirely in accordance with the indications afforded 
by the general disease. The same may be said of those cases which orig- 
inate in connection with abscesses in the lungs, or suppurative pericar- 
ditis, or extensive suppurative processes in any other parts of the system. 
The renal affection being secondary entirely may hasten the fatal result, 
but does not alter the fact that the indications for treatment are covered 
by the morbid conditions and processes which had existed prior to its oc- 
currence. If cases of diffuse suppurative inflammation occur as the result 
of direct blows, injuries, or from any causes that render the renal affection 
the primary one, it is probable that treatment promptly resorted to of the 
same character which I have mentioned as applicable for acute nephritis 
in its early stage, would be most likely to relieve the patient, by either 
preventing or lessening the extension of the suppurative process. But in 
these cases, the stage preceding the suppurative process is short; and of- 
tentimes is passed before the attention of the physician is attracted to the 
case, or the true diagnosis has been made. But when suppuration is 
once established, the great object of the treatment must be to sustain the 
patient by judicious use of nourishment, and when, as is often the case 
the stomach refuses to accept or retain food, nutritive enemas must ba 
substituted. Such remedies as are calculated to sustain the patient mort 
or less, and can be used hypodermically, may be employed in that manner 
Something may be done by inunction or the introduction of nutrimen 
through the skin. All these modes may be resorted to for the support of 
the patient and prolongation of life, in the hope that the accumulation of 
pus will either be relieved spontaneously through free discharge into the 
pelvis of the kidney and through the urinary passages with the urine, or 
that it may assume such a position or relation as to be reached by incis- 
ion from the exterior behind the peritoneum, and allow of drainage in that 
way. But you will perceive that these measures at once bring the case 
within the domain of practical surgery, where you must look for detailed 
directions for such operative procedures. In cases of pyelitis arising from 
the existence of calculi in the pelvis of the kidney, the treatment must 
consist in the administration of such remedies as are calculated to allay 
irritation in the mucous membrane of the urinary passages generally; 
such tonics and nutrients as promote the general nutrition and strength 
of the patient, avoiding exercise, especially upon the feet, or in the up- 
right position, which is calculated by the free motion of the calculi to add 
to the irritation and often to occasion hemorrhage. If in the progress of 
the case such symptoms are developed as render the diagnosis reason- 
ably certain that such calculi exist, and have become too large to 
be voided, it brings the important question, whether the operation of 
nephrotomy, by which the calculi may be reached and removed shall be 
ventured upon or not. Where there is but a single large calculus free to 
move in the pelvis of the kidney, and the patient is of good constitution, 
the surgeon may undertake an operation for its removal with reasonably 
fair prospect of success, as it constitutes probably the only hope of pre- 
serving the patient from a long, wasting, painful sickness and ultimate 
death. As there are no remedial agents known that are capable of dis- 



638 FLUXES. 

solving these calculi, their continued presence sooner or later exhausts the 
patient and leads to coincident affections which shorten life. 



LECTURE LX. 



Fluxes— Definition and Varieties— Cutaneous Flux, or Diaphoresis -Its Causes, Pathology and 
Treatment. 

GENTLEMEN: In the sixth lecture 'of the present course while speak- 
ing of the classification of diseases, or their arrangement into con- 
venient groups to secure order in their consideraton, I arranged those de- 
nominated local diseases in four sub-classes or orders, namely: inflamm a- 
tions, fluxes, neuroses and a group of miscellaneous affections. Having 
completed the consideration of those classes denominated local inflamma- 
tions, so far as they come within the scope of what is regarded, at the 
present day, as practical medicine, I now invite your attention to the dis- 
eases and morbid conditions included in the second division under the 
designation of fluxes. You will remember, that in the lecture just alluded 
to, I stated that this term was not an entirely satisfactory one, having 
relation only to a symptom which may be common to all the morbid 
conditions included under that designation, and having no pathological 
significance on the one hand, and no indications as to the particular or- 
gans or tissues that might be involved in the disease upon the other. 
And yet, as all the diseases included in the group are characterized by 
an unusual flux or flow of fluids, I am not able to select a better 
term. In the lecture to which I have alluded, you will find a table in 
which the diseases and morbid conditions included in this division are ar- 
ranged, first into two groups; the one characterized by the flow of serous 
fluids derived from the blood, and hence called serous fluxes; and the 
other characterized by the flow of blood itself, and hence called sanguin- 
eous fluxes or hemorrhages. (See page 51). The serous fluxes were 
again divided into two groups, the one taking place from the free sur- 
faces, and the other into shut sacs or interstitial spaces of tissue. As 
the free surfaces of the body are made up or constituted mainly of the 
cutaneous tissue upon the exterior surface of the body, and of the mucous 
membrane lining the alimentary canal and other cavities having external 
outlets, the flow from these surfaces is at once discharged instead of ac- 
cumulating in contact with any part of the body. When the flow is from 
the cutaneous surface exteriorly, it takes the name of diaphoresis, or sweat- 
ing. When it takes place from the internal free surface of the mucous 
membrane of the alimentary canal, it gives rise to discharges either by 
vomiting, purging, or both, and is generally recognized as serous diar- 
rhoea, cholera morbus, cholera infantum or epidemic cholera, according to 
the rapidity and copiousness of the discharge. When the flow of serous 
fluid takes place into the shut sacs like the membranes of the brain, 
pleura, pericardium, peritoneum, synovial membranes, bursal sacs, or into 
the parenchyma of organs, it has no way to escape except by absorption, 
and consequently accumulates, distending the parts, constituting what is 
known as dropsical accumulations. It then takes various names, indicated 



DIAPHORESIS. 639 

in a great measure by the name of the sac in which it may accumulate, 
as hydrocephalus, hydrothorax, ascites, an I when in the interstitial 
spaces, oedema or anasarca. In the consideration of this group of dis- 
eases, I shall follow the order in which they were presented in the table 
given in the sixth lecture to which I have already alluded, and will con- 
sequently direct your attention first to the fluxes from the free surfaces 
of the body. 

Diaphoresis. — The eliminations from the cutaneous surface, pissing as 
they leave, from the fluid to the vaporized form, accomplish, in the healthy 
condition of the system, two important purposes. One is excretory, free- 
ing the blood from certain portions of the waste materials that have been 
derived from the molecular processes in the tissues of the body, and the 
other is to diminish the temperature by constantly converting a portion of 
the free heat into a latent condition in the conversion of the fluid on the 
sarfaca into the aeriform state. Cutaneous exhalation, therefore, consti- 
tutes an active cooling process, provided by nature for counterbalancing 
the tendency to accumulate heat by the constant conversion of latent into 
free heat in the different processes taking place in the living tissues. 
The quantity of exhalation from the cutaneous surface varies much 
within the limits of health. 

As a rule, it may be said that the amount of exhalation from the cu- 
taneous surface, in the healthy condition, is in direct ratio to the temper- 
ature of the surrounding atmosphere, provided the hygrometric condition 
or that of moisture be the same. But a dry atmosphere at the same 
temperature invites a much more rapid exhalation than a moist one, from 
the simple physical fact that the atmosphere is capable of holding only a 
certain amount of aqueous vapor in solution before it reaches the point 
of saturation. Hence, an individual can maintain health in a dry atmos- 
phere, at a much higher temperature than in a moist one; as the ex- 
perience of each one of you has demonstrated, if you remember the dif- 
ference in the effects of two summer days of the same temperature as in- 
dicated by the thermometer, but in one of which the air is dry, in the other 
the air is saturated with moisture. The comfort, and even buoyancy in the 
first, contrasts strongly with the oppressive character of the second. I 
call your attention to these circumstances relating to health and every- 
day life, that you may the better appreciate not only the function of the 
cutaneous tissue so far as relates to exhalations or fluxes from it, and the 
natural effects which are produced, but also the morbid conditions and 
their remedies. For while the cutaneous exhalation may vary much in 
quantity in a given time within the limits of health, if it is out of correspond- 
ence with the relations of the surrounding atmosphere, it is frequently 
in icative of some pathological condition needing correction. Without 
going minutely into details, in regard to all the causes that influence ex- 
halations from the surface of a morbid character, we may group them into 
three divisions: First, those which simply increase the temperature of the 
surrounding medium. Second, those that produce impairment of the gen- 
eral tonicity by lessening the vital affinity of the tissues, including the 
cutaneous, and thereby inducing such general relaxation as to favor ex- 
cessive exhalation of the watery or serous element of the blood through 
any of the free surfaces of the body. And, third, those causes that act 
more directly upon the vasomotor nerves controlling the vessels of the 
periphery or surface of the body. In regard to the cases that arise from 
the first of these causes, namely, the direct increase of the temperature of 
the surrounding medium or atmosphere, I may point you, as the most 
familiar illustration, to the effects of the high temperature of every sum- 



640 DIAPPIORESIS. 

mer. As I have before stated, all other things being equal, the higher 
the temperature of the air in which we live, the greater is the amount of 
cutaneous transpiration. An excess of such exhalation rapidly diminishes 
both the saline and watery elements of the blood. For, as you are aware, 
the perspiration contains an important amount of the saline constituents, 
especially chloride of sodium, which is an important element in healthy 
blood. It is a physiological law, that whenever from any process the 
watery element of the blood escapes in too large proportion, it leads to a 
demand for drink, or thirst for fluids on the part of the patient. Conse- 
quently, the general habit of the community during the warm season of the 
year, while perspiration is going on sufficiently active to prove a source of 
exhaustion of the water and saline elements of the blood, is, to take pro- 
portionately larger amounts of water, or of some kind of diluent fluid to 
supply the place of such exhalation. As a general rule, however, the 
more copious the supply of fluids by drink, the more copious also will be 
the cutaneous transpiration. The result is, that a large part of the com- 
munity during the highest temperature of summer, by the quantity of 
water and other fluids they drink, directly encourage the flow of the 
cutaneous exhalation, which carries with it a much larger proportion of the 
saline elements of the blood, especially the chlorine salts, than are sup- 
plied by the water and liquids that are taken; and the consequence is, 
that the blood is kept deficient in its free salts. It was long ago ascertained 
by Bernard, and since confirmed by many others, that the capacity of the 
blood to take up oxygen from the air cells of the lungs and hold it in so- 
lution to be distributed through the system with the arterial blood, de- 
pends in part, at least, upon the saline constituents existing in the serum. 
You can readily see, therefore, that whenever the saline elements, and 
more especially the chlorine salts of the blood, are diminished below their 
natural proportion, it also diminishes the capacity of the blood for re- 
ceiving oxygen from the air cells of the lungs, and consequently, dimin- 
ishes the efficiency of the process of oxygenation and decarbonization of 
that fluid. The result qf such deficiency is, that the nervous system feels 
the depression, consequent on the presence of defectively arterialized 
blood, giving rise to a sense of weakness, weariness and inability for active 
exertion. At the same time the gastric tubules and other secreting cell 
structures in different organs, feel the want of a more fully arterialized 
blood, and consequently fail to maintain the healthy performance of their 
natural functions. 

The appetite becomes impaired, the food digests less readily from the di- 
minished amount of gastric secretion, causing gastric and intestinal derange- 
ments; and it is in this way that we have a full and satisfactory explana- 
tion of the large amount of minor ailments that are so prevalent in the 
community during the heat of every summer. And in certain classes of 
the community, those especially who are working at all seasons of the 
year in places exposed to a very high temperature, as is the case with 
some of the workmen in iron foundries, rolling mills and manufacturing 
establishments requiring the presence of high heat, copious perspiration 
causing dryness of the mouth and craving for drink, induces a very copious 
supply of fluids. I have had occasion every year, for many years, to ex- 
amine and prescribe for workmen from such places in this city, who, 
under the circumstances, had acquired the habit of drinking from six to 
twelve litres (quarts) of water or other diluent drinks every day during 
the regular hours that they were exposed to a high temperature; and at 
the same time perspired so copiously as to fully counterbalance the 
amount of their drink. The result has been such as I have mentioned, a 



TREATMENT. G41 

few moments since; the exhaustion of the free salts of the blood, dimin- 
ished oxygenation and decarbonization, leaving the skin clammy and 
cool, the countenance haggard, the lips a leaden hue, under the finger 
nails more or less bluish or leaden, extreme weakness and almost total 
suspension of gastric secretion and digestion, with marked diminution in 
the quantity of urine. It is not only this class, however, that suffer, 
although they give us the most complete demonstration of the extreme 
derangements produced by this process, but there are thousands engaged 
in no work as well as those who are busy during the summer season, that 
follow the habit of indulging so largely in drinks as to keep up excessive 
exhalations from the surface with the same consequences I have detailed, 
varying only in their degree. 

Of course the treatment which such patients require, consists mainly 
in the proper regulation of their diet and drinks. I have found by an 
abundant trial, that nearly all acute cases of the fluxes liable to result 
from these causes, whether it be from the high heat of summer, or by ex- 
posure to the high temperature of certain kinds of work, can be avoided 
by the simple rule, that the patient, after taking such an amount of wa- 
ter, milk and water, or other simple diluents, as weak tea or weak coffee, at 
the time he takes his food as he may desire, between the meals, he shall 
never take more than thirty or sixty centimeters ( fl. |i or pi) at one time. 
Such drink may be either cold water, milk whey, buttermilk, or water 
slightly acidulated with acetic acid and flavored with a little syrup. As 
often as the mouth becomes dry and uncomfortable, taking for drink 
simply this small quantity of cold water, or any of the other drinks I 
have mentioned, moistens the membranes of the mouth, fauces and 
oesophagus and produces a cooling impression upon the stomach, which 
continues just as long as would be the case, if they took half a litre (or 
pint) of a similar fluid at once. The quantity taken does not alter the 
time at which the feeling or desire for more drink is reproduced. But 
by limiting the amount taken at any one time, directly to the quantities 
I have specified, most individuals would consume no more than half 
a litre or one pint in the interval between breakfast and dinner, and a 
similar quantity between dinner and supper. The consequence is, that 
under such a rule in regard to drinks, the amount of exhalation from 
the cutaneous surface is greatly diminished. The free salts of the 
blood are consequently retained, and the blood maintains very nearly its 
natural proportion of constituents throughout. The strength of the in- 
dividual is also conserved, the secretions are maintained in their natural 
condition. I have given the rule to a great many, who had been suffer- 
ing from the conditions I have mentioned, and I have yet to find a single 
individual practicing it faithfully, who has not thereby obviated all the 
evil effects from which they had previously suffered. It is now more than 
thirty years since my attention has been directed to this 'particular sub- 
ject, and I am satisfied that a ver}- large percentage of the minor ail- 
ments of every summer, and also many of the more severe attacks of 
cholera morbus and diarrhoea, originate from the influences to which I 
have been alluding. It is hardly necessary for me to say that the evil 
effects of drinking large quantities of water, and other diluent drinks in 
the encouragement of perspiration and loss of a large proportion of the 
saline elements of the blood, are in no wise lessened by the mixture of 
alcoholic beverages with the water or other diluents that are taken. In 
other words, that a little whisky or brandy will in no wise mitigate the 
evil, but on the contrary the mixture of alcohol in any form, whether as 
distilled or fermented liquors, directly and positively adds to the evil bv 
41 



G42 DIAPHORESIS. 

still further diminishing the oxygenation and decarbonization of the blood. 
Indeed, I have never found the water in any part of the world so bad, but 
that the addition of alcohol would make it worse for drinking purposes. 

The second group of causes to which I have alluded, namely, those which 
produce excessive exhalation from the surface by causing relaxation or 
impairment of the general tonicity of the tissues are chiefly connected 
with, or dependent upon, previously existing diseases, such as the ex- 
treme impoverishment of the tissues in the progress of consumption, 
chronic diarrhoea, chronic dysentery, the collapsing stage of acute gen- 
eral diseases, and of choleraic affections. You will learn as you watch at 
the bedside, that the last stages of almost all general diseases of an acute 
character, and of those local affections that cause death by asthenia or 
exhaustion, that the patient reaches a stage before actual dissolution in 
which the tissues become so impaired by the predominance of waste owr 
that of nutrition, that there is an almost constant tendency to exces- 
sive exhalation from the whole cutaneous surface, usually giving it a 
cold, clammy feeling, at the same time it is bathed with an exudation of 
the watery element of the blood standing in drops upon the surface. 
This is well known as the colliquative or cold perspiration that beto- 
kens the speedy coming of death, and yet, it sometimes exists for days 
before the final cessation of life. However, in many of these cases coinci- 
dently with the relaxation of the surface and excessive exhalation, the free 
surface of the internal mucous membrane becomes similarly relaxed, and 
a colliquative diarrhoea goes on parri-passu with the excessive diaphoresis 
until the muscular structures, no longer controlled by the involuntary nerve 
force, relax as indicated by the failure of the sphincters, and the appearance 
of the involuntary discharges that precede death. How far the serous 
diarrhoeas that take place in young children so generally, especially -in the 
more densely populated districts and cities during the highest heat of every 
summer and the more severe attacks of cholera morbus are dependent 
directly upon the relaxing influence of continuous high temperature, is 
perhaps difficult to determine. That it is this influence of high temper- 
ature continuing day and night for a succession of days, that exerts a very 
important influence, I shall have occasion to demonstrate to you by an 
abundant array of facts when I come to consider more in detail these 
diseases. 

The third group of causes to which T alluded as capable of producing 
excessive diaphoresis, were those which operate through the vasomotor ner- 
vous system chiefly, if not exclusively. That there are agents which may 
thus act is easily demonstrated by watching the operation of certain medi- 
cines. The prompt effect of pilocarpine in so modifying the condition of 
the cutaneous vessels and the salivary glands as to cause copious exuda- 
tion of fluid from both, giving free diaphoresis and excessive flow of 
saliva, and the almost equally prompt manner in which belladonna and 
various other agents are capable of producing exactly the reverse effect, 
so altering the cutaneous capillaries and those of the mucous membrane 
and glandular structures belonging to the mouth, as to arrest transpiration 
from the one and secretion from the other almost totally, show that the-e 
functions are capable of being acted upon by special agents, both in the 
direction of inducing excessive diaphoresis on the one hand, and of 
almost entirely arresting exhalations on the other. And it is probable 
that a large number of cases are met with in practice, characterized 
by excessive sweating, whether in the sweating stage of periodical fevers, 
or the copious sweats of hectic fever, or the almost hourly vacillations 
from chilliness, dryness and free sweating that we see in some patients in 



TEEATMENT. G43 

particular periods of life, more especially in the female during transition 
from the continuanoe of the menstrual flow to that of their final cessa- 
tion, and sometimes for a year following its final discontinuance, and 
of some others that might be named, which are specimens of excessive cuta- 
neous transpiration, undoubtedly directly dependent upon modifications 
of the vasomotor influence over the cutaneous vessels. It is true, that 
in all those cases which occur in connection with general fevers, or with 
hectic, septicemic or pyemic conditions, the treatment must be prin- 
cipally that which is necessary and proper for the existing disease on 
which the cutaneous transpiration depends, and with which it is con- 
nected as an incident. You will meet with numerous cases, especially 
those which occur in connection with wasting disease of the hectic type 
inducing exhaustive night sweats, as well as those less important but 
much more numerous, occurring at the period of change of life, as it is 
termed, in which you will find it necessary to prescribe not only for the 
general condition, but for the purpose of directly influencing this partic- 
ular symptom. 

In all cases, attention should be given fully and carefully to the condi- 
tion of all the functions of the patient, and in directing treatment, such 
directions should be given as are calculated to correct whatever is mani- 
festly out of order. In those cases which occur at the period of change of 
life in females, the remedies that I have found most efficient for remov- 
ing the cutaneous relaxation and sweats, which so inconvenience many of 
these patients, by causing alternate chills and sweating at short intervals, 
many times every day, are, a combination in the form of pill or capsule, of 
the oxide of zinc, ergotin, and extract of scutilaria, in the proportion of 
two decigrams (gr. iii) of the oxide of zinc, and six centigrams (gr. i) 
each, of the ergotin and extract of scutilaria, in a capsule; one of which 
may be given each morning, noon and night. If the bowels are habitually 
inclined to be costive, as is often the case in these patients, the ad- 
dition of two centigrams (gr ^) of pulverized aloes or extract of col- 
ocynth to each capsule, will usually obviate this difficulty, without inter- 
fering with the beneficial influence of the other constituents in any de- 
gree. For the excessive diaphoresis usually indicated by the frequent 
night sweats existing in connection with suppurative conditions in the 
lungs, or any other parts of the body, we may use with advant ge often- 
times three classes of remedies, namely: those which are calculated to 
lessen the suppurative process, and thereby retard the progress of the 
primary disease and its consequences; such tonics as increase the general 
tonicity of the tissues, thereby lessening the relaxation of the surface; and 
such direct vasomotor tonics as increase the tone of the vessels of the 
periphery, and more directly and immediately prevent the occurrence of 
the periodical sweats. Among the first of these remedies I have found 
none more efficient than a combination of pure glycerine and the syrup 
of iodide of iron for lessening suppuration in the advanced stage of 
phthisis, with profuse night sweats, and in many other internal suppura- 
tions. 

I have usually mixed these constituents in the proportion of four parts 
of pure glycerine, with one of the syrup of the iodide of iron, giving to 
adults from two to four cubic centimeters (fl. 3ss to 3i) of the mixture, 
largely diluted with water, from three to four times in the twenty-four 
hours. I have seen many cases in which the amount of pus formed was 
much diminished during the use of this combination, and coincidently the 
night sweats were also correspondingly mitigated. Another combination, 
which produces a similar though not quite as active an effect in 



644 SEROUS DIARRHCEA, ETC. 

these suppurative conditions, is that of sub-nitrate of bismuth, sub- 
carbonate of iron, and minute doses of morphine or codeine. This is 
particularly applicable to the suppurative stage of tuberculosis, after the 
patient has become exhausted to such a degree as to induce more or less 
irritability of the stomach and diarrhoea as well as night sweats. But for 
the immediate control of the copious sweats of all forms of hectic as well as 
many of the more important toxic conditions that are accompanied by 
profuse perspiration, I have found no remedies that were equal to ergotin 
when given in doses of two decigrams (gr. iii) three times a day; or the 
extract of belladonna, given in just such doses as the patient will bear with- 
out producing uncomfortable dryness of the mouth and fauces, or impair- 
ment of vision by dilatation of the pupil of the eye. But the ergotin has 
succeeded in my hands more satisfactorily, for this particular purpose than 
any other remedy that I have used. It is unnecessary, however, to con- 
sume } r our time by further details in regard to. the etiology and treatment 
of excessive fluxes from the cutaneous surface, because the remarks which 
I have already made, concerning the modus operandi by which remedies 
act in the production of excessive diaphoresis, and the different modes 
by which remedies may be brought to bear, either as tonics upon the 
general system, or as special agents for improving particular functions, 
and still more particularly as vasomotor agents in acting directly, at such 
times as we may use them, upon the condition of the circulation in the 
periphery, you will see clearly the principle on which you can act in any 
and all cases that may come before you for consideration. I will conse- 
quently leave this class of cases and next direct your attention to the 
fluxes from the free surfaces within, or more particularly from the mucous 
membrane of the alimentary canal, considering them under the names of 
serous diarrhoea, cholera morbus, including the cholera morbus of chil- 
dren, which is more generally styled cholera infantum and epidemic 
cholera. 



LECTURE LXI 



Serous Fluxes from <he Mucous Membrane of the Alimentary Canal— Serous Diarrhoea— Cholera 
Morbus, and Epidemic Cholera; their General History and Etiological Relations. 

GENTLEMEN: The group of affections included under the heads of 
serous diarrhoea or " summer complaint" — and cholera morbus — pre- 
vail most in the middle part of the temperate zone. In this country that 
part lying between the 31° and 42° parallels of latitude and east of the 
Rocky Mountains, gives a much higher ratio of their prevalence, than the 
partsfurther north or south or on the Pacific coast. It is within the belt 
first named that we have the greatest range of temperature, the difference 
between the coldest days of winter and the highest heat of summer being 
from 24° to 60° C. (75° to 140° F.) with an average high range of sum- 
mer heat for, at least, two consecutive months. It is in the large cities 
and more densely populated towns within this territory that the intesti- 
nal affections under consideration are so prevalent, especially among young 
children that they regularly add from 50 to 75 per cent to the gross mortal- 
ity during the months of July, August and September of each year. It is 



ETIOLOGY AND PROPHYLAXIS. 645 

directly upon the southern border of this same belt or zone of the earth's 
surface, as it extends through the southern part of Europe and Asia that 
epidemic cholera most frequently makes its appearance, and from which 
it has apparently spread at different times over a large part of the civil- 
ized world. Without further general remarks I wish to limit your atten- 
tion during the remainder of the present hour, to the causes and clinical 
history of serous diarrhoea and cholera morbus as they occur in both chil- 
dren and adults. In doing so I shall make use of the same facts and 
much of the same language, that I incorporated in a brief paper on the 
"efficient causes" of these affections, read to the Section on Diseases of 
Children, at the meeting of the American Medical Association in June, 
1882. 

Etiology and Prophylaxis. — When it is remembered that one third of 
the human race perish before they reach five years of a^e, and that a 
large percentage of these early deaths are the direct result of attacks of 
serous diarrhoea and cholera morbus in infancy, it will be conceded that 
no subject is more worthy of careful study than the etiology and prophy- 
laxis of these affections. I mention etiology and prophylaxis together, 
because all measures designed to prevent diseases must be intelligently 
adjusted either to the removal of the efficient causes or to a neutraliza- 
tion of their effects, else they will fail to accomplish any useful purpose. 
Nearly all the public sanitary and hygienic measures which characterize 
the present stage of civilization, are aimed at the removal or prevention 
o: the causes of disease, both predisposing and exciting. But there are 
many etiological influences of great potency in either predisposing to or 
exciting attacks of disease, which are not under human control. The 
problem presented for consideration concerning these, is not how to pre- 
vent or destroy them, but how best to shield the human system from 
their injurious effects. For instance, bad food may be destroyed and that 
which is good substituted in its place; bad and impure air in dwellings 
may be displaced by ventilation; soils wet and impregnated with decom- 
posable vegetable and animal matter may be improved by drainage and 
cultivation; but the meteorological conditions of the atmosphere, whether 
they relate to impurities, sudden and extreme changes, or waves of con- 
tinuous high or low temperature, are not subject to our control, and 
yet much can be done to mitigate or prevent their injurious effects. 
Nearly all the recent writers on practical medicine and on diseases of 
children class the cases of serous diarrhoea and cholera morb-us in children 
under two years of age, usually called " summer complaint " and " cholera 
infantum," with the local inflammations under the general name of catar- 
rhal gastro-enteritis. And while they all assert that these forms of dis- 
ease are most prevalent and fatal during the warmest months of summer, 
they set forth as the chief causes improper feeding, impure and changed 
milk, impure and confined air, the progress of dentition or " teeth- 
ing," and overworked, badly fed, and unhealthy mothers and nurses. 
All these causes are represented as producing either gastric or intes- 
tinal indigestion or both, which so increases the irritation of the mucous 
membranes as to cause a more or less rapid serous exudation into the gas- 
tric and intestinal canal with excessive evacuations. It will be noted 
that indigestion, is very generally alleged as the immediate cause of the 
so-called catarrhal irritation and excessive discharges; while the indiges- 
tion is in turn regarded as the result of bad feeding, impure air, teething, 
and unhealthy mothers or nurses. Dr. Flint and others have placed 
much emphasis on the influence of the adulterated and poor qualitv of 
milk distributed in our large cities. That the milk so distributed is often 



646 DIARRHOEA AND CHOLERA MORBUS. 

of poor quality, and is productive of gastric and intestinal derange- 
ments, and that all the other causes enumerated are often the occasion of 
similar derangements, I freely admit. But I am quite certain that a 
more careful and extended clinical study will show that none of the causes 
usually enumerated really exert more than a minor influence over the 
production of the so-called summer complaint and cholera infantum that 
prove so destructive to infantile life in many of our cities and populous 
towns every summer. For instance, a moderate degree of attention will 
show that the errors in feeding infants, the adulterations of milk and im- 
purities of other food, and the unsanitary condition of dwellings, are quite 
as prevalent in all communities during the winter as the summer. It is 
quite certain that in every community there are, on the average, as many 
children cutting their teeth in December and January as in July and Au- 
gust; and I have been wholly unable to find any larger proportion of un- 
healthy, badly fed, or overworked mothers or nurses at one part of the 
year than another. It is quite certain that if any one or all of these agen- 
cies exerted a prominent or controlling influence in determining attacks 
of serous diarrhoea and cholera infantum, such attacks would be met with 
frequently at all seasons of the year. Yet, both the records of the com- 
mencement of attacks and the statistics of mortality show that the prev- 
alence of all grades of these two forms of disease is restricted almost en- 
tirely to the ninety days intervening between the last week in June and 
the last in September. 

Thus, in Chicago, in 1877, only 2 deaths from cholera infantum are 
reported in the statistics of the Health Department during the months of 
November, December, January, February and March; 8 in April; 6 in 
May; 23 in June; 246 in July; 163 in August; 69 in September; and 13 
in October. Again, in 1875 and 1876, I obtained the date of the com- 
mencement of 351 cases of serous diarrhoea and cholera infantum, of 
which 61 commenced in June, 197 in July, 66 in August, and 27 in Sep- 
tember, and none during the remaining months of those years. The 
ratio of prevalence thus found to exist in the various months of 1875-6-7, 
in Chicago, will be found to fairly represent the ratio every year, and in 
all the Northern and Eastern cities of our country. If we turn our atten- 
tion in another direction, we will be met by still greater difficulties in 
accounting for the prevalence of these bowel affections on the supposition 
that they are produced by the causes to which they have usually been 
attributed. For instance, the mortuary statistics show that the diseases 
under consideration prevail but little in cities so located that there is only 
a short range of temperature between the warmest days of summer and 
the coldest days of winter, and where, from sea breezes or otherwise, the 
summer nights are cool. 

There is no evidence within our knowledge which shows that the milk 
distributed in San Francisco and New Orleans is any purer or of better 
quality than in Boston and Chicago. Neither are the nursing mothers any 
more free from mental and physical infirmities, nor the sanitary conditions 
of the dwellings, sewers, etc., more perfect in the two former than in the 
two last-named cities. Yet an examination of the mortality statistics of 
these several cities shows a ratio of only about five deaths from cholera 
infantum annually for every 10,000 inhabitants in San Francisco, and 7 
in New Orleans, while Boston gives about 25 and Chicago 30 deaths 
from the same disease for every 10,000 of their inhabitants. The fore- 
going facts show conclusively that there must be some efficient cause or 
causes which determine the prevalence and fatality of the diseases under 
consideration that are not common to all large cities and all aggregations 
of civilized people. 



ETIOLOGY. 647 

Their prevalence at certain seasons of the year only, and chiefly in cer- 
tain climatic regions, shows conclusively that they are dependent on 
causes which are operative under some circumstances not common to all 
civilized communities. 

To determine what these circumstances are, I commenced, many years 
since, to keep a record of the date of beginning of all attacks of serous 
diarrhoea and cholera infantum coming under my observation, in connec- 
tion with the coincident meteorological conditions of the atmosphere, and 
for three years coincident records of a similar character were kept by 
active practitioners in Cairo, Illinois; Davenport, Iowa; and Omaha, 
Nebraska. Reports giving the results of these investigations were made 
in the Medical Section of the American Medical Association, and pub- 
lished in the Transactions for 1875, 1877 and 1879, to which I must refer 
you for details. Those investigations were sufficient to establish the fol- 
lowing important conclusions: 

First. — That the prevalence of the affections under consideration is 
limited principally to the months of July, August and September, com- 
mencing with the first wave of high atmospheric heat that continues day 
and night for more than five days, which in the latitude and altitude of 
Chicago is sometimes the last week in June, but more frequently the 
first week in July, and continuing more or less during the succeeding 
ninety days. 

Second. — That while the number of deaths from these affections in 
any city or given community will be nearly the same in the two first 
months after they begin — that is, July and August — the date of the 
initial symptoms, or beginning of the disease in three fourths of all 
the cases will be in July, very few originating after the first of August. 
Many cases that commence in July, and partially recover, are found to 
relapse or become worse during certain waves of high temperature in 
August; and a large percentage of those attacked in July continue wast- 
ing with the disease until relieved by death throughout the months of 
August and September. 

Third. — That it is not simply high or extreme heat of temporary dura- 
tion, such as that of a single da}' or of any number of days with cool 
nights, which favors the development of serous diarrhoea and cholera infan- 
tum, but continuous high temperature day and night through several days 
in succession. 

And if, in addition to the high heat, the air be stagnant, as from lack of 
winds, or from obstructions, as in large and compactly built cities, or 
from defective ventilation of dwellings, the morbific effects are greatly in- 
creased. This explains why these affections are more numerous and fatal 
in cities than in rural districts, and why they prevail so little in large 
cities located in warm climates, provided the location be such as to afford 
cool breezes at night, as is the case in San Francisco and New Orleans, 
already alluded to. 

Fourth. — That while the great majority of attacks which occur in any 
given summer are found to have their beginning in July, or during the 
first thirty or forty days after the first wave of protracted high tempera- 
ture for the season, they are not equally distributed over the whole of the 
month, but are almost all traceable to a limited number of days and 
nights coincident with the waves or periods of continuous high tempera- 
ture. From observations extending over twenty years in Chicago and 
three years in Cairo, Davenport, and Omaha, I have found that the special 
waves or periods of high temperature day and night vary in duration 
from three to fourteen days. When they do not extend beyond three 



648 DIARRHOEA AND CHOLERA MORBUS. 

days, the effect on the number of attacks of serous diarrhcei and cholera 
infantum is slight. In Chicago, many summers have passed without a 
single period of continuous high heat of more than three or four days' 
duration, and such have uniformly been accompanied by a low ratio of 
infant mortality from bowel affections. In a majority of the seasons, 
however, there have been found three of those periods of continuous high 
temperature between the 25th of June and the 31st of July, each from 
five to seven days in duration. And the attacks of serous diarrhoea and 
cholera infantum have increased so rapidly that the number of deaths 
from these alone has caused the aggregate mortality of July to be more 
than double that of June. Much more rarely a season has occurred in 
which one of these periods of continuous heat day and night has com- 
menced during the last week in June or first week in July, and continued 
with but little variation for two or three weeks. Such seasons have uni- 
formly been characterized either by a prevalance of epidemic cholera or 
an extraordinary mortality from the serous fluxes in children. 

Having thus traced the origin of that part of infantile mortality caused 
by the affections just named to the coincidence of continuous high atmos- 
pheric heat with a minimum of atmospheric currents, let us inquire, for 
a moment, how this combination of circumstances can affect the living 
human body. 

First. — You have the physical law that the higher the temperature of 
the air the rarer it becomes, and the less oxygen is contained in each 
cubic inch. Consequently an individual breathing a given number of 
times per minute, and a given number of cubic inches of air at "Z7° C. (81° 
F.) would receive into the air cells of his lungs much less oxygen per hour 
than one breathing the same number of times and the same number of 
cubic inches of air at 18° C. (65 c F.) 

Again, a still or stagnant atmosphere, whether from the absence of 
winds or currents without, or of ventilation within, becomes more rapidly 
exhausted of its oxygen and impregnated with impurities from the 
breathing of living beings than one actively changed by currents and free 
ventilation. 

Second. — The physical law of expansion by increase of temperature 
applies to living as well as to dead matter. Consequently continuous high 
heat, acting on the living human body, tends to increase the distance of 
the atoms or molecules from each other, and thereby lessen the force of 
vital affinity or general tonicity of the tissues, while it increases the ex- 
citability or susceptibility to impressions. 

Third. — The capacity of the blood for taking up oxygen or holding it 
in suspension, depends much on the proportion of saline elements it con- 
tains, and under a continuous high temperature the increase of cutaneous 
exhalation rapidly diminishes the free salts of the blood, especially the 
chloride of sodium, and thereby directly lessens its capacity to receive the 
oxygen from the air-cells of the lungs in exchange for its carbonic acid 
gas. It is hardly necessary to add, that on the degree of oxygenation and 
decarbonization of the blood depends the sensibility and natural action 
of the vasomotor and all other portions of the nervous structure of the 
body. Here, then, you have in these waves or periods of high summer 
heat the coincidence of less oxygen to the cubic inch of inspired air; less 
capacity of the blood to take up and hold it in solution; less general tonic- 
ity of the textures of the body, with increased excitability of the mucous 
membranes and cutaneous surfaces from the direct stimulus of external 
heat. The two first of these conditions, by lessening the oxygenation and 
decarbonization of the blood, directly diminishes the influence of the 



PATHOLOGY. C49 

vasomotor nerves over the tone of the vessels of the morbidly excitable 
mucous surfaces of the alimentary canal, and thereby favors serous exuda- 
tion instead of either natural secretion or absorption. Thus, by first es- 
tablishing the coincident conditions under which serous diarrhoeas and 
cholera infantum actually occur, and, second, by analyzing these condi- 
tions by the application of known laws of physics and physiology, you are 
enabled to see clearly the exact pathological conditions induced — namely, 
a morbidly sensitive condition of the mucous membrane of the alimentary 
canal, in conjunction with such a diminution of general tonicity and 
special impairment of vasomotor nerve influence as to impair the natural 
secretory actions, and directly establish more or less exudation of the se- 
rous elements of the blood. In a large proportion of these cases the re- 
sulting serous exudation is only sufficient to render the natural evacuations 
thinner and more abundant, constituting the mildest form of " summer 
complaint." From this you have all grades of severity up to an entire 
suspension of secretory action, and so rapid an exudation as to cause 
the copious vomiting and purging of an active cholera morbus; so copious 
indeed, sometimes, as to exhaust the water and salts of the blood, and in- 
duce fatal collapse in a few hours. The essential pathological conditions 
are, general impairment of tonicity of the tissues with deficient oxygena- 
tion of the blood, and special impairment of the vasomotor nervous in- 
fluence over the vessels of the mucous membranes of the stomach and in- 
testines. The exudation constituting the discharges results from these 
pathological conditions and has no necessary connection with any grade 
of inflammation, catarrhal or otherwise. Inflammation of portions of the 
mucous membrane often supervenes as a complication during the progress 
of protracted cases. 

But ilio-colitis and recto-colitis or dysentery seldom occur until later 
in the season, when warm days are followed by cool nights, and frequent 
changes to wet and cold. And even the indigestion which has been so 
generally suggested as a cause of " summer complaint " is itself the result 
of the impairment of natural gastric and intestinal secretions and the in- 
crease of mere serous exudation; the primary fault not being so much in 
the quality and quantity of the food, as in the morbidly sensitive and 
relaxed condition of the whole inner surface of the digestive canal. The 
r?asons why the children under two years are affected so much more severely 
than older persons, are, the less mature development and greater sensi- 
tiveness of their gastric and intestinal mucous membranes and glandular 
structures, and their much more constant confinement indoors. 

If the foregoing views are correct, they indicate clearly that our efforts 
to lessen infant mortality from serous diarrhoea and cholera morbus must 
embrace such measures as will secure for young children a better supply 
of fresh, pure air for increasing the oxygenation and decarbonization of the 
blood and maintaining the activity of the vasomotor nervous system, and 
as will counteract the effects of high temperature by increasing the general 
tonicity and lessening the excitability of the tissues generally. Measures 
for the first object must consist in securing better ventilation of dwell- 
ings, and especially of nurseries and sleeping-rooms during the warmest 
part of the summer; the sending of young children, with their mothers 
and nurses, from cities and densely populated districts, to moderately ele- 
vated healthy locations, or to floating hospitals or receiving ships on large 
bodies of water during the special periods of continuous high temperature. 
For accomplishing the second purpose, I know of no measures that are so 
efficient, and, at the same time, within the reach of the poorest part of the 
population, as the judicious use of the sponge bath. Whenever the hu- 



G50 DIARRHOEA AND CHOLERA MORBUS. 

man system is relaxed, and rendered morbidly sensitive by continuous 
high heat, causing the infant to be languid, restless, and sometimes pale, 
a free bathing or sponging of the whole surface with water simply, as 
cool as is comfortable, always produces a refreshing and invigorating in- 
fluence, which continues from six to twelve hours. Consequently, if 
mothers and nurses could be so instructed by their family physician that 
during every wave or period of high atmospheric temperature, in which 
the mercury did not fall below 21° C. (70° F.) during the nights, they 
regularly gave each child under two years of age a full sponge bath in 
the evening as well as in the mornirig, and kept their sleeping-rooms as 
well ventilated as possible, it would diminish the number of attacks of 
serous diarrhoea and cholera infantum one half, and consequently very 
greatly lessen the infant mortality from these affections. 

It is well known to every careful observer, that a large majority of all 
the attacks of this form of disease show their first beginning during the 
last half of the night or early in the morning, owing to the long continu- 
ance of the high temperature, coupled with the more still and confined 
air of the night. The increased tone of the whole vascular system pro- 
duced by the stimulant and tonic effect of a comfortably cool sponge bath 
on the function of the vasomotor nerves, applied in the evening, would 
enable thousands of these little, restless sufferers to pass the whole night 
unharmed, when without it the dreaded sickness would begin. 

Symptoms or Clinical History. — Both for convenience and accuracy 
of description, I shall divide the intestinal summer complaints or fluxes of 
both children and adults into three groups. In the first group I shall em- 
brace those cases in which the patient is suddenly attacked with copious 
vomiting and purging of serous fluid, which, after the first two or three 
evacuations becomes very thin, sometimes tinged yellow or green from the 
presence of the coloring matter of bile, and in other cases hardly staining 
the napkin. 

Under the depleting influence of these evacuations the countenance 
becomes pale, the eyes sunken, the pulse small and frequent, the extrem- 
ities cold and shrunken, the urine scanty or entirely suppressed, and the 
mind dull or inactive, with brief spells of great restlessness. In the more 
severe attacks these results follow so rapidly that fatal collapse is reached 
in from six to twenty-four hours. 

In most cases, however, after the first eight or ten hours the discharges 
become less frequent and copious, the vomiting being limited to the re- 
jection of drinks, whenever too much is allowed to accumulate in the 
stomach; an J the passages from the bowels to from one to four or five in 
the twenty-four hours. As very little nourishment is either retained or 
assimilated, the patients continue to emaciate, and if not relieved by 
app:opriate treatment, will usually reach the stage of fatal exhaustion 
in from one to three weeks. In the advanced stage of some of the cases 
there occurs a constant wakefulness or morbid vigilance, with rolling of 
the head, tossing of the hands, and frequent moaning. 

Such symptoms are apt to induce the parents and nurses to think that 
the disease has "gone to the head." And I have known several cases 
presenting these symptoms, in which the attending physician had made 
cold applications to the head, blisters behind the ears; and in three cases, 
even leeches and a cathartic of calomel were resorted to under the im- 
pression that the symptoms indicated the supervention of inflammation in 
the brain or its membranes. It is hardly necessary for me to remind you 
that the symptoms mentioned were the result of cerebral anaemia or defi- 
cient supply of blood to the brain instead of inflammatory action. 



SYMPTOMS. G51 

Excessive losses of blood will often produce much discomfort in- the 
head, accompanied by wakefulness, frequent turning of the head from side 
to side, and sometimes delirium. This anaemic condition of the brain, 
from whatever cause, may be distinguished from inflammation or active 
hyperemia by noting the size of the pupils of the eyes, the tension of the 
carotid arteries, and in infants the condition of the anterior fontanelle. 
All grades of cerebral inflammation are accompanied at first by contrac- 
tion of the pupils, fullness and hardness of the carotids, and convexity or 
bulging of the fjntanelle; and it is not until the inflammation has termi- 
nated in effusion sufficient to cause compression that the pupils become 
dilated. But you must remember that the same amount of effusion which 
would produce compression and dilatation of the pupil, would also pro- 
duce stupor or coma and still more fullness of the fontanelle; while in 
the anaemic condition of the brain, the dilated pupils and staring expres- 
sion of the countenance are accompanied by sleeplessness instead of. 
stupor by softness of the carotids, and by a sunken or concave fontanelle. 

A large proportion of the cases I have included in this first group, after 
presenting the active symptoms of cholera morbus for the first few hours, 
instead of proceeding to a dangerous or fatal degree of exhaustion, un- 
dergo a different change. The vomiting ceases and the intestinal dis- 
charges become less frequent, smaller in quantity, contain some mucus and 
are sometimes streaked with blood. At the same time more or less febrile 
reaction comes on, causing the skin to become dry and warmer than 
natural, especially over the trunk of the body and in the palms of the 
hands; the pulse to be more full and. frequent; and indications of abdom- 
inal pains just before and during the evacuations. 

These are cases in which the rapid exudation from the ilio-colic mem- 
brane furnishing the material so actively vomited and purged during the 
first stage, so far detaches the epithelial layer as to favor true inflamma- 
tory congestion before the stage of extreme or fatal exhaustion, which 
converts them into cases of true ilio-colitis with secondary fever, as I point- 
ed out to you when speaking of the various grades of inflammation in 
the alimentary canal. 

In the second group of cases I include all th.se that commence with 
mere thin or serous evacuations from the bowels, with little or no pain or 
vomiting, and without pyrexia; and this embraces much the larger num- 
ber of all the bowel affections that occur during the summer months. 
The intestinal evacuations in the cases belonging to this group vary much 
in frequency, color, and consistence. 

In some cases they are from the beginning so thin and colorless as 
to look like turbid water in the vessei, and to leave hardly a stain on the 
napkin in young children. Yet the quantity voided is so large as to pros- 
trate the patient very rapidly, causing the skin to become blanched and 
cool, the eyes sunken, the pulse small and weak, with all the indications 
of approaching collapse within a few days. In many of these cases the 
discharges after continuing long enough to induce a decided deficiency 
in the watery and saline constituents of the blood, and much general 
weakness, become smaller in quantity, less frequent, and mixed with 
some mucus. At the same time slight febrile symptoms supervene, caus- 
ing increased heat in the abdomen, and if the patient be a child, it be- 
comes more fretful and peevish. The intestinal discharges in different 
cases vary much in color, being in some cases green, in others pale yellow, 
and in still others a little turbid like rice water. They vary also much 
in consistency and odor, being in some cases thin as water and nearly 
odorless, and in others only semi-fluid, frothy, and extremely offensive. In 



G52 CHOLERA MORBUS. 

most casos some of the food or drink taken by the patient can be identi- 
fied in the evacuations, together with numerous epithelial cells from the 
surface of the mucous membrane. 

The urine is generally scanty in proportion to the copiousness of the 
intestinal evacuations. In many cases if tbe disease is not interfered 
with by treatment, the patients continue steadily to lose flesh until the 
emaciation is as complete as in the last stage of pulmonary tuberculosis, and 
death supervenes from simple asthenia or inanition, at periods varying 
from one to three months from thp commencement of the attack. In 
nearly all the adults and in a large proportion of the children, however, 
after the disease has continued from one to four weeks, the discharges be- 
gin to improve both in number and quality, digestion and nutrition be- 
come more active, and in a few weeks the patients regain a fair degree of 
health. In a small proportion of cases, especially of young children, the 
recovery is only partial. 

The stomach and duodenum apparently regain their natural condition; 
the child takes food well, and appears cheerful, but the intestinal dis- 
charges continue more frequent than natural, are semi-fluid or frothy, 
light yellow or grayish color, and usually very offensive. 

They, also, often contain curds of milk or coagulated casein and par- 
ticles of other undigested food. The urine, though generally less than 
natural, often contains an excess of the phosphates and-lithates, which af- 
ford an abundant white or milky looking deposit when the urine stands 
until cold. With the foregoing symptoms the patient may continue sev- 
eral months, with a good appetite and an abundance of nourishment, and 
yet he loses flesh or becomes more emaciated everyday. But the abdo- 
men gradually increases in size, partly from flatulency and partly from 
hypertrophy of the mesenteric glands, until its prominence makes a 
strong contrast with the emaciated extremities. The cases that assumed 
this form were formerly called cases of tabes-mesenterica or marasmus, 
and sometimes continued one or two years before ending in death or re- 
covery. 

The third group of cases generally included under the head of "sum- 
mer complaint" or intestinal flux, are distinguished from the two preced- 
ing groups by the presence of distinct febrile action at the beginning of 
the attack. With the first occurrence of vomiting or purging, or both, 
the skin is warmer and dryer than natural, the lips are parched, the pulse in- 
creased in frequency, and the patient more fretful with indications of more 
or less griping pains in the abdomeu. If vomiting exists it is generally a 
retching or straining to vomit, with only a slight discharge of thin mucus, 
sometimes colorless but frequently tinged yellow or green from the 
coloring matter of bile. Of course much of whatever food or drink is 
taken is directly ejected by vomiting. The intestinal evacuations are 
generally small in quantity containing some mucus, frequent, and imme- 
diately preceded or accompanied by indications of griping pains in some 
parts of the abdomen. You will not fail to recognize these symptoms as 
indicating an inflammatory condition of the intestinal mucous membrane, 
identical with what I have already described under the class of local in- 
fl immations. When the disease is limited to the ilium and upper part of 
the colon, the discharges are usually thin or serous with some inter- 
mixture of mucus, and of a green or yellow color. When the lining of 
the lower part of the colon and rectum is the part chiefly affected, the 
evacuations are small, mucous, sometimes mixed with blood and accom- 
panied by tenesmus or straining. But the symptoms, progress, prognosis 
and treatment of this class of cases I have already fully discussed 



ANATOMICAL CHANGES. 653 

in the lecture on ilio-colitis, etc., and only give this brief description 
again because they are so frequently met with in the latter part of the 
summer and early part of autumn intermingled with the true serous 
intestinal fluxes and not always differentiated from them. 

Anatomical Changes. — The visible structural changes found on the 
post-mortem examination of those who have died during the progress of 
gastro- intestinal fluxes will vary much in accordance with the duration of 
the disease before the fatal termination. 

When death has taken place from collapse during the active stage 
of copious s"rous discharges, the mucous membrane is found extensively 
denuded of its epithelial layer, with here and there patches of redness 
which more resemble* ecchymosis than inflammatory changes, and in some 
parts a degree of softening of the texture is easily recognized. 

When death has resulted from asthenia after several weeks of exhausting 
discharges without febrile action, the mucous membrane of the intestines, 
like the other tissues of the body, is paler and more attenuated than natural 
with many superficial abrasions, more particularly throughout the ilium and 
colon. In the case of a child eighteen months old who died in the thkd 
month of a wasting serous diarrhoea which had commenced early in July, 
I found on making a careful post-mortem examination, in addition to the 
generally pale and shrunken condition of the tissues a remarkably atten- 
uated and bloodless condition of the whole alimentary canal, including the 
mucous membrane, which was carefully examined throughout its whole ex- 
tent. Only slight abrasions were found in portions of the membrane lining 
the ilium and colon. Many of the mesenteric glands were moderately en- 
larged. 

When death has taken place at any time after the occurrence of the 
febrile reaction and the change in the discharges to a more mucous char- 
acter, as I have already described, the post-mortem examination will re- 
veal more distinct inflammatory changes in different parts of the intestinal 
mucous lining. 

Prognosis. — In adults and in children over five years of age attacks 
of serous diarrhoea and cholera morbus rarely terminate fatally. Oc- 
casionally, however, cases occur in the vigorous period of adult life in 
which the copiousness of the discharges, both from the stomach and 
bowels, is such as to produce all the phenomena attributed to well marked 
cases of epidemic cholera, ending in profound collapse and death in less 
than forty-eight hours. But they are rare exceptions to the general rule 
of recovery. In infants or children under three years of age the results 
are widely different, the mortality being so great as to add more than fifty 
per cent, to the gross mortality of the months of July, August and Sep- 
tember, in all the large cities and populous towns in the middle and north- 
ern part of the United States. But the prevalence of the disease is limited 
mostly to the months just named, and the mortality to children under three 
years of age. 



654 SEKOUS DIARRHOEA. 



LECTUEE LXII. 



Serous Diarrhoea and Cholera Morbus, continued— Their Pathology and Treatment. 

GENTLEMEN: In the preceding lecture I directed your attention to 
the general history and etiology of the diarrhoeal affections, more 
frequently called " Summer Complaints," which constitute so important 
a part of the sickness of every summer, especially in young children. 
From a careful review of the causes set forth as radst efficient in deter- 
mining the prevalence of this class of diseases and their modus operandi, 
as then explained, you have probably already inferred the most important 
items of their pathology. In that lecture I endeavored to show that all 
the causes and circumstances which favored the production of serous diar- 
rhoea and cholera morbus, whether in children or adults, co-operated to 
produce an increase of the susceptibility or irritability of the mucous 
membrane of the alimentary canal, and at the same time to diminish the 
vital affinity, and consequently the tonicity of the whole vascular system. 

This morbid excitability, coupled with impaired tonicity of the mucous 
membrane, constitutes the primary pathological condition in all the first 
and second groups of cases mentioned in the preceding lecture. The 
morbid excitability of the membrane invites a rapid influx of blood into 
it, while the diminished vital affinity and consequent relaxation of texture 
admit of equally rapid effusion or exudation of the serum or watery ele- 
ments of the blood, thus furnishing the material for the copious and thin 
discharges. The rapid diminution of the watery element of the blood, 
carrying with it more or less of the saline constituents, in such discharges, 
speedily diminishes also all the glandular secretions such as urine, bile, 
gastric and salivary juices, etc., and retards the molecular changes in all 
the tissues which involves both diminution of temperature and notable 
shrinking of the whole body. The morbid sensibility of the nervous fila- 
ments involved in the mucous membrane, acted upon by the effused fluid, 
calls into action a reflex influence upon the muscular coat, thereby increas- 
ing the peristaltic motion and the frequency of the evacuations. 

Such are the pathological conditions which constitute the active stage 
of the affections now under consideration. These morbid conditions can 
not exist long, however, without inducing other pathological changes of 
equal importance. For instance, the rapid exhaustion of the water and salts 
of the blood from a continuance of the discharges, soon renders that fluid 
too viscid to circulate freely through the capillary system or vessels, while 
the copious exudation carries with it a large amount of the epithelial cells 
of that membrane. 

If the vomiting persists to such an extent as to prevent the retention of 
drinks long enough to afford any replenishment of the water in the blood, 
there will be danger of an entire suspension of the capillar}^ circulation 
and a speedily fatal collapse. In a very large majority of the cases, how- 
ever, the increased viscidity of the blood so alters its relations to the 
capillary vessels of the mucous membrane as to stop the effusive or serous 
exudation spontaneously, before the stage of collapse is reached. When 
the discharges thus cease before collapse ensued, rest and a careful replen- 
ishment of the blood by liquid nourishment soon establishes natural 
molecular and secretory actions, and health is restored in a 1 trge propor- 
tion of cases. But in a smaller number of cases, it happens that when the 



TREATMENT. (SOD 

discharges have ceased, and a healthy reaction has taken place in the tis- 
sues generally, there remain patches of the mucous membrane from which 
the epithelium has been detached so completely as to materially impede 
the capillary circulation in them. 

In other words, to cause passive congestion first and subsequently a low 
grade of inflammatory action accompanied by moderate febrile reaction, 
which may continue from one to three or four weeks. 

If the congested and inflamed patches are located chiefly in the mem- 
brane lining the ilium, the general symptoms will strongly resemble those 
>f enteric or typhoid fever; if in the colon, both the intestinal discharges 
•,nd the grade of fever will more closely resemble those of dysentery, as 
described when giving the clinical progress of the different groups of 
cases yesterday. But the mucous membrane is not the only structure in 
which the capillaries miy fail to resume their functions when the active 
discharges have ceased, and the stige of reaction his come. When the 
attack of cholera morbus has been severe, and the amount of serous dis- 
charge by vomiting and diarrhoea so great as to produce a very marked 
deficiency of water in the blood, the latter may become so altered in rela- 
tion to the capillaries of the brain, that the circulation becomes too feeble 
to sustain the function of the cerebral hemisphere. In such cases, though 
the intestinal discharges may cease, the circulation and warmth be restored 
in the extremities, and a general appearance of healthy reaction be estab- 
lished, yet the patients pass into a state of partial or complete coma from 
which they seldom recover. 

Another, and perhaps more frequent local failure in the resumption of 
capillary and molecular actions, is in the kidneys. In the preceding lect- 
ure I stated that one of the early effects of copious serous or thin dis- 
charges from the lining of the alimentary canal, was a partial or complete 
suppression of urine. Clinical observations show that such suppression 
of urine continues after a fair re-establishment of natural action through- 
out the rest of the system, in some cases. The consequence is that symp- 
toms of ura3m : c poisoning soon supervene. Such are the chief pathological 
conditions presented in the development and progress of the first and second 
groups of cases described in the preceding lecture. 

The mildest class of cases of simple looseness of the bowels or slight 
"summer complaint" present only the two primary morbid conditions 
consisting of increased susceptibility and diminished tonicity sufficient to 
cause a moderate excess of serous exudation into the intestinal canal. 
But the protracted continuance of even this moderate drain may produce 
any or all of the subsequent pathological conditions I have described, as 
fully as the more severe and rapidly exhausting attacks of cholera morbus 
or cholera infantum. 

Treatment. — What I have said in regard to the pathology of the impor- 
tant class of diseases under consideration, points directly to the following 
plain indications for fulfillment in their therapeutic management: 

a. To allay the morbid sensitiveness or irritability of the mucous mem- 
brane of the alimentary canal. 

b. To restore the general tonicity of the tissues and of the vaso-motor 
nervous system. 

c. To properly regulate the diet, drinks and general hygienic surround- 
ings of the patient. 

To fulfill the first two indications named you need the combined influ- 
ence of an anodyne and tonic; the first to allay the morbid sensitiveness, 
the second to increase the general tonicity of the tissues. In the early 
stage of mild cases, characterized by mere thinning of the intestinal 



656 SEROUS DIARRHOEA. 

discharges and a fueling of lassitude with a little paleness, I have lone 
been in the habit of using small doses of some preparation of opium ir 
combination with a mineral acid, as in the following formula: 

5 



Acidi Sulphurici Aromatici 


10 


c. c. 


3iiss 


Tincturae Opii 


10 


u 


3iiss 


Syrupi Simplicis 


15 


(C 


3iv 


Aquae , 


60 


u 


!" 



Mix. Of this, four cubic centimeters (fl. 3i) may be given to an adult 
in a little sweetened water, two, three or four times a day, according tc 
the effect desired. To an infant from eight to sixteen months old the 
dose should not be more than from six to ten minims at the same intervals 
of time. Or the following, which is milder and perhaps preferable foi 
young children: 

$ Acidi Hydrobromici 30 c. c. §i 

Elixer Simplicis 30 " fi 

Tincturae Opii Camphoratae 30 " |i 

Mix. This may be given in the same doses both to adults and children 
as directed of the preceding formula, and diluted also with water when 
given. 

If in addition to the moderate diarrhoea, the more important secretions 
are checked as shown by the absence of the coloring matter of bile from 
the intestinal discharges, and the scanty amount of urine, one of the fol- 
lowing powders may be given each morning and evening in addition to 
one of the liquid prescriptions: 

^ Hydrargyri Chloridi Mitis 0.20 grams gr. iii 
Sodii Bicarbonatis 0.40 " gr. vi 

Sacchari Albi 2.00 " gr. xxx 

Mix. For an adult divide into four powders, and for a child twelve 
months old, divide into twelve or fifteen powders. The use of these 
should be discontinued as soon as the intestinal evacuations become yel- 
low or green from the presence of bile. 

In young children, when the disease has already continued in a mild 
form for one or two weeks, and the discharges give an offensive or sour 
smell and contain undigested casein or curds of milk, or items of other 
nourishment, the anodyne and acid formula may give place to the fol- 
lowing: 

]J Acidi Carbolici 0.20 grams gr. iii 

Glycerin se 10.00 c. c. 3iiss 

Tincturae Opii Camphoratae 30.00 " |i 

Aquae Cinnamomi 45.00 " Jiss 

Mix. To children from eight to sixteen months old, from ten to twelve 
minims may be given in half a teaspoonful of sweetened water every 
Pour,*six or eight hours according to the frequency and quantity of the 
discharges. 

In nearly all the mild cases the judicious use of some one of the fore- 
going formulae, with a proper regulation of the nourishment and the daily 



TREATMENT. 657 

access to fresh, pure air, will he sufficient to speedily restore the patients 
to health. But when the attacks are more severe, constituting- what I 
described in the preceding lecture as cholera morbus or cholera infan- 
tum, and the matter vomited yields a sour odor, I order a solution of 
bicarbonate of sodium four grams (3i), and sulphate of morphia six centi- 
grams (gr. i) in sixty cubic centimeters (^ii) of water; of which J give 
from six to fifteen minims, according to the age of the child, immediately 
after each paroxysm of vomiting. At the same time, if the discharges 
from the bowels are frequent and very thin like water, I give one of the 
following powders every three or four hours until they are diminished: 

1£ Hydragyri Chloridi Mitis 0.20 grams gr. iii 

Plumbi Acetatis 0.20 " " gr. iii 

Pulveris Opii 0.06 " gr. i 

Sacchari Albi 2.00 " gr. xxx 

Mix. For a child aged six months, divide into twelve powders; twelve 
months eight powders; eighteen months six powders. 

The rule to give whatever medicine is designed for the direct suppres- 
sion of vomiting in small doses immediately after each paroxysm of vom- 
iting is one of much practical importance. Vomiting is an act that can 
not be performed continuously, but must always occur in paroxysm, with 
an interval of greater or less length between them. Therefore, if you 
give a dose of medicine immediately after a paroxysm of vomiting, it will 
remain in contact with the lining membrane of the stomach a few minutes, 
at least, before another effort to vomit can be made. During these few 
minutes, if the medicine is soluble, or already in solution, it will make 
some impression both on the nervous filaments and on the capillaries of 
the mucous membrane; and a prompt repetition of the dose after each 
paroxysm of vomiting will soon accumulate an effect sufficient to destroy 
the morbid sensibility and thereby stop the vomiting. But if you follow 
the wishes of the patient and the inclination of almost all nurses, by waiting 
for the former to " rest a little," or for the stomach to get " settled," that lit- 
tle period of rest will be sufficient for the muscular coat of the stomach to 
have regained its contractility, and the mucous membrane to have poured 
out a new supply of serous fluid, and consequently the patient is ready 
for another paroxysm of vomiting. Now if you administer the dose 
of medicine it is almost certain to be rejected as soon as it is swallowed 
and you gain no influence over the morbid conditions. The same rule is 
important in reference to the use of enemas for aiding in the suppression 
of diarrhoea or dysentery. They should be administered as soon after an 
evacuation as possible, for the longer they are delayed the more will the 
mucus or serum and other contents of the bowels have accumulated in the 
rectum and the more readily will the introduction of an enema be followed 
immediately by its expulsion. These details are given you, because suc- 
cess in the treatment of the more active gastric and intestinal affections 
of a choleraic nature, depends quite as much on the time and manner of 
administering the medicine, as upon the kind of medicine used. 

Some cases, both of serous diarrhoea and cholera morbus are met with 
every summer, in which the discharges, instead of being sour and destitute 
of the coloring matter of bile, are bitter and highly colored with the latter 
fluid, thereby showing a superabundance instead of deficiency of the biliary 
secretion. In such cases, instead of giving alkalies or alkaline salts and 
mercurials, all of which increase more or less the glandular secretions, I 
resort directly to small and frequently repeated doses of anodynes and 

42 



C58 SEROUS DIARRHCEA AND CHOLERA MORBUS. 

astringents, of which the combination of acetate of morphia and acetate of 
lead are the most efficient, or more frequently to the following anodyne 
and antiseptic formula: 

^ Acidi Carbolici 0.20 grams gr. iii 

Glycerinae , 15.00 c. c. 3iv 

Tincturas Opii Camphoratae 30.00 c. c. §i 

Aquae Cinnamomi 45.00 c. c. giss 

Mix. Give to children between six and eighteen months old from ten 
to twenty minims every one or two hours in active serous diarrhoea, and 
after every paroxysm of vomiting in the active stage of cholera infantum. 

You must keep constantly in mind the important clinical fact, that in 
all cases of copious intestinal evacuations, the urine is liable to become 
scanty, and that the suppression of such evacuations by opium and astrin- 
gents often leaves the secretory action of the kidneys very defective and 
sometimes entirely suppressed. This result can be very generally avoid- 
ed by giving the following prescription in doses suited to the age of the 
patient: 



Spiritus Etheris Nitrosi 


15.00 c. c. 


3iv 


Tincture Digitalis 


4.00 c. c. 


3i 


Syrup i Simplicis 


15.00 c. c. 


3iv 


Aquas 


60.00 c. c. 


§ij 


Potassii Acetatis 


12.00 grams 


3iii 



Mix. To an adult four cubic centimeters (fl. 3i), and to a child twelve 
months old ten or fifteen minims may be given every two, three or four 
hours, according to the effect desired. 

In some of the more active cases of summer diarrhoea and cholera mor- 
bus, after the first stage has passed, the vomiting ceased, and the intesti- 
nal discharges reduced to one in from two to four hours, a low grade of 
febrile action is set up causing dryness of the mouth, much thirst, restless- 
ness, considerable griping pains before each evacuation, and more or less 
mucus mixed with the thin faa?es; thus bringing them fairly within what 
I described yesterday as the third or more inflammatory group of in O ;ti- 
nal affections. In nearly all of such cases the following emulsion will be 
found one of the most efficient that can be used: 



I£ Olii Terebinthinae 




8.00 c. c. 


3ij 


Olii Gaultheriae 




2.00 c. c. 


3ss 


Tincturae Opii 




8.00 c. c. 


3ij 


Mucilaginis Acaciae 




15.00 grams 


3iv 


Sacchari Albi 




15.00 grams 


3iv 


together thoroughly and 


add: 






Aquae 




90.00 c. c. 


|ui 



Mix. Direct the nurse to shake the vial, and give to children between 
eight and eighteen months old from eight to twelve minims, every three, 
four or six hours, according to the frequency of the discharges, until the 
latter become consistent and natural. 

When cases of serous diarrhoea or summer complaint have become 
chronic and accompanied by much emaciation, with coolness of the sur- 
face and extremities, the intestinal discharges continuing thin and too 



2.00 grams 


gr. xxx 


4.00 c. c. 


3i 


30.00 c. c. 


li 


15.00 c. c. 


§ss 


45.00 c. c. 


?isa 



TREATMENT. 659 

iroquent, but without dysenteric straining or any notable intermixture of 
mucus, the remedies should contain some element of a more tonic charac- 
ter. 

In such cases I have often directed the following formula, with much 
benefit to the infantile class of patients: 

]fy Phloridzinae 

Spiritus Ammonii Aromatici 
Tincturae Opii Camphoratas 
Syrupi Simplicis 
Aquae 

Mix. To children under two years of age give from ten to twenty 
minims three or four times a day. The phloridzine is derived from the 
bark of apple-tree root, and is a mild tonic not unpleasant to the taste 
and agreeable to the stomach, while the camphorated tincture of opium 
supplies the necessary anodyne influence. Another formula which I have 
occasionally used in the same class of cases is as follows: 

i£ Erigerontis Canadensis 15.000 grams 3iv 
Quiniaa Tannatis 1.300 grams gr. xx 

Morphiae Sulphatis 0.066 grams gr. i 

Mix. Pour on the whole, half a liter or one pint of boiling water to 
make an infusion. When it is cold you can give to a child one year old 
four cubic centimeters or one teaspoonful, to which a little sugar may 
be added, every three, four or six hours. This combination has the ad- 
vantage of being moderately diuretic and tonic while it is efficiently 
anodyne and astringent. In some very protracted cases, accompanied by 
an anaemic condition of the blood, I have seen very good results obtained 
by giving suitable doses of the liquor ferri nitratis, morning, noon and tea- 
time, and one of the following powders at bed-time: 

3 Quiniae Tannatis 0.200 grams gr. iii 

Pulveris Opii - 0.065 grams gr. i 

Hydrargyri cum Cretae 0.200 grams gr. iii 

Sacchari Albi 1.500 grams gr. xx 

Mix. Make into six powders. 

In the treatment of this important class of bowel affections I have thus 
given you an unusual number of prescriptions or combinations, not for 
the purpose of encouraging either polyphamary or over medication, but 
rather for the purpose of enabling you to select from the variety some 
one calculated to meet the indications in each individual case ; 
and at the same time to illustrate the value of combining agents to meet 
more perfectly the coincident indications presented in different stages of the 
progress of the same case. The maxim that a thorough knowledge of the 
nature and capabilities of a few remedies is better for the practitioner than 
an imperfect knowledge of many, is doubtless true. But it is equally true 
that a thorough knowledge of many remedies, even of the same class, is 
much better than such knowledge of only a few. For nothing is more 
certain than that every active practitioner who relies on treating almost 
all cases of disease with some one of half a dozen remedies with which he 
has become clinically familiar will every now and then find himself cor- 
nered at the bed-side, or at the end of his therapeutic resources, by some 



660 SEROUS DIARRHCEA AND CHOLERA MORBUS. 

unusual feature of the disease or idiosyncracy of the patient. And this will 
happen in the management of no class of diseases more frequently than in 
those classed as bowel affections of children. 

Thus far I have said little or nothing in regard to the nourishment for 
this class of patients, and yet it is a matter of the highest importance. In 
all cases occurring in infancy, if the child can have good breast milk, 
either from the mother or a healthy wet nurse, it is preferable to any or 
all other articles that have been devised. 

But if artificial food must be provided for these little sufferers, I am 
satisfied from many years of observation that there is nothing better 
than good, fresh cow's milk, to which may be added lime water, in the 
proportion of four parts of the milk to one of the lime water. If this 
combination is sweetened a little, either with white sugar or sugar of 
milk, it will possess as near the properties of the mother's milk as anything 
that can be used. One of the most common errors in the feeding of very 
young children consists in diluting the milk, or whatever else may be 
used, too much. Nothing is more common than to give infants, under 
six or eight months old, simple bread or cracker water, or a mixture of 
one part of cow's milk with two or three parts of water, slightly sweet- 
ened with sugar. Of course the more nourishment is diluted with water 
the larger must be the quantity taken to afford a given amount of material 
capable of being converted into elements for the growth and repair of the 
tissues of the body. And I have seen many an infant worrying day and 
night from the combined sensations of hunger and colic, while its stomach 
and bowels were filled to repletion with bread-tea, toast water or a mixt- 
ure of one part of milk with three of water. The correct rule for our 
guidance in selecting food for j T oung children, especially when they are 
suffering from morbid sensitiveness of the mucous membrane of the 
alimentary canal, is to get as much of the elements capable of being con- 
verted into nutritious material as possible into a small compass or bulk, 
and yet have it bland and easy of absorption by the vessels of the stom- 
ach. There is no substance that fulfills these requirements better than a 
thin, well boiled gruel of pure sweet milk and wheat flour. 

One teaspoonful of such gruel contains more material capable of be- 
ing converted into flesh and blood than two tablespoonsful of a mixture 
of one part milk and three parts of water and is far more likely to be re- 
tained and absorbed by the stomach. 

Another object of great importance in the management of the class of 
diseases now under consideration, especially as they affect young children, 
is to obtain for them access to fresh and pure air. Their confinement in 
small, overheated and badly ventilated rooms is one of the most efficient 
causes of their sickness and mortality. 

Consequently, so far as possible, all chronic cases should be removed to 
hilly and healthy districts of country, or to boats or ships floating on large 
bodies of water. When neither of these is practicable a short ride in an 
open carriage or buggy, every day, and the maintenance of thorough ven- 
tilation and cleanliness in the rooms they occupy, will constitute the best 
substitute. 



EPIDliMIC CHOLERA. 661 



LECTURE LXIII. 



Epidemic Cholera -Its History, Causes. Symptoms, Pathological Changes, Diagnosis, Progn sis 
and Treatment 

GENTLEMEN: The subject which will occupy our attention the 
present hour is one of much interest, and on which volumes have 
been written, both in this country and Europe. I allude to epidemic 
cholera, which has also received the names of cholera asphyxia, cholera 
algid a, spasmodic, malignant, Asiatic, and Indian cholera. 

I prefer to call the disease epidemic cholera, simply because it serves 
to distinguish it from common sporadic or endemic cholera morbus, with- 
out implying any theory of either its nature or origin. 

History. — Some descriptions in the writings of Areteus have been sup- 
posed to aDply to this disease, and Professor Martin Hoag has claimed to 
have found some distinct references to it in the ancient Sanscrit writings; 
but the earliest reliable accounts we have of its prevalence are by D'Orta, 
in 1563, at Goa, and during the seventeenth century by Bontius of Ba- 
tavia, and Willis, Morton and others in England. In 1733, Morga^ni in 
Italy, and in 1736, Degner in the Netherlands, described the prevalence 
of epidemics having much resemblance, at least, to the genuine epidemic 
cholera. In 1781-2, the disease prevailed and proved very fatal in Cal- 
cutta, Madras, and Ceylon. The first great migratory epidemic of which 
we have any account, commenced at Jassore, in August, 1817, and soon 
after at Calcutta. During the next five years its ravages were extended 
to almost every populous town in China, the south of Asia, the East In- 
dia Islands, and as far westward as the eastern border of the Mediterra- 
nean sea. In 1831 it made its appearance in Europe, and prevailed destruc- 
tively in many of the more populous districts and cities, from Archangel, 
in 64° north latitude, to the borders of the Mediterranean south, before 
the end of the year. The following year it became almost equally preva- 
lent for the first time on this continent. 

It was first recognized in Quebec on the 8th of June, 1832. A few days 
later it was also prevailing in Montreal, New York and Albany, and before 
the end of the summer months it had manifested its destructive presence 
in the principal cities of twelve States, extending from Boston to New 
Orleans. During the two following years it visited prominent places in 
Mexico, the West India Islands, and from 1834 to 1837, it again severely 
scourged nearly all the countries in the South of Europe and in Central 
America. Daring the next decade nothing was seen or heard of its prev- 
alence in any part of Europe or America. In 1847, however, it severely 
attacked a Russian army west of the Caucasus, and during the year 1848 it 
revisited almost every country in E trope. Late in the autumn of that year 
the disease developed on board of two emigrant ships in mid-ocean, the 
one sixteen and the other twenty-seven days out from Havre. They were 
nearly one thousand miles apart at the time the disease appeared on 
board, the one being bound for the port of New York, the other that of 
New Orleans. In the latter city the disease developed into a very se- 
vere and fatal epidemic almost immediately after the arrival of the vessel 
in the month of December. But it showed no signs of prevalence in the 
city of New York until the latter part of April, 1819, and did not reach 
decided epidemic prevalence until the latter part of June, July and 



662 EPIDEMIC CHOLERA. 

August. During these months, however, it prevailed more or less in 
nearly all the more populous cities and in many of the country districts 
throughout the United States and Canada. From 1849 to 1854, the disease 
reappeared each summer in many of our cities, more especially those 
on the great interior lakes and in the lower part of the valley of the 
Mississippi; but in the summer of the last named year it became more 
generally prevalent and was more fatal. 

During the years 1854 and 1855, it revisited many parts of Europe, after 
which it disappeared from the countries on both sides of the Atlantic until 
1865, when it again became prevalent, first in Egypt and Arabia, and 
later in several places in Europe. During the following year, I860, the 
disease visited the more prominent places in the southern and central pacts 
of Europe and reappeared also in many cities in this country. In 1867-8, 
its chief prevalence was in Central and South America, and in some of 
the West India Islands. During the summers of 1871-2, it was 
again quite prevalent in Europe; and in the summer of 1873 it manifested 
a remarkable prevalence in some of the cities and purely agricultural dis- 
tricts in the States of Tennessee, Kentucky, Ohio, Indiana, and Illinois. 
During this and the following year the disease was also prevalent in some 
parts of South America, more especially in Buenos Ayres, where it proved 
very fatal. Since that date, 1874, the disease has prevailed in variable de- 
grees of severity in some parts of India, or the south of Asia, almost every 
year; and during the past summer, 1883, it has manifested an extraordi- 
nary prevalence in Egypt, but has not noticeably prevailed in any part of 
Europe or America. From this very brief historical sketch, you will see 
that thus far during the century, there have been three extraordinary 
periods of epidemic prevalence of the cholera in Europe and America. 
The first commenced in 1831 and continued until 1837; the second ex- 
tended from 1847 to 1855; and the third from 1855 to 1874. A less no- 
ticeable period of epidemic prevalence commenced in 1817 and continued 
until 1822, but was confined mostly to Asia and the countries and islands 
east of the Mediterranean. Confining our attention to this country and 
Europe, it would appear that during this century, the epidemic periods of 
cholera prevalence have varied from five to nine years, while the interval 
or period of exemption has not varied much from ten years. If this gen- 
eral rule is to continue, we may expect the commencement of another 
epidemic period for Europe and America next summer, or at the longest, 
the summer following. Both in regard to the number of persons attacked 
and the ratio of morality during the prevalence of an epidemic, the 
cholera must rank among the most severe scourges of the human race. 
Like all the more important acute non-contagious diseases capable of 
periods of wide-spread epidemic prevalence, the epidemic cholera appears 
to have a permanent habitat, or natural home, where it is more or less prev- 
alent every year. This home is in India, where it is as much an endemic 
as the yellow fever is in the West Indies. 

Causes of Epidemic Cholera. — All the causes or influences that I 
enumerated in the two preceding lectures, as favoring the production of 
attacks of serous diarrhoea and cholera morbus, also act as predisposing 
influences favoring the prevalence of epidemic cholera. The chief of 
these influences are continuous high temperature, still, or stagnant and 
damp air, with such atmospheric impurities as arise from badly ventilatod 
rooms, and from the presence of the products of decomposing organic 
matter either in the soil or water, or both. 

That local conditions pertaining to organic impurities in the soil, water 
and atmosphere, have an important causative influence in the production 



ETIOLOGY. 663 

and spread of epidemic cholera, is clearly apparent from the facts ac- 
companying every epidemic. A detail of these facts would occupy too 
much of your time in the lecture room, consequently I will refer only to 
some of the more prominent, which may guide you in studying them fur- 
ther at vour convenience. First, the disease has never, in this country 
at least,been known to prevail as an epidemic in elevated country dis- 
tricts, presenting primitive geological strata, with uneven surfaces, rapid 
streams, and pure water. For instance, during the epidemic of 1849, in 
New York City, hundreds and thousands fled from direct contact with 
the disease in the city to the highlands up the Hudson river, and to the 
mountains of Vermont and New Hampshire, and though some sickened 
and died on the way, in none of these regions did the disease manifest 
any disposition to prevail. But along water courses skirted by alluvial 
deposits, and over comparatively level and especially malarious districts, 
the disease has spread, and often proved as fatal in proportion to the num- 
ber of inhabitants as in the most populous cities. See History of its 
Prevalence in the Mississippi Valley in 1873. Second, in all the cities 
and districts where it prevails, the attacks are much more numerous and 
severe in the low, damp, and uncleanly streets and neighborhoods, than 
in those presenting the opposite sanitary conditions.* 

Third, in every epidemic of cholera, the ratio of attacks and of mor- 
tality has been much greater in that part of the population characterized 
by uncleanly and intemperate habits, and those of foreign birth, than in 
any other classes. This was strikingly illustrated in the prevalence of chol- 
era in this city (Chicago) in the summer of 1873. In that season, al- 
though a few well marked cases occurred in other parts of the city, its 
prevalence was limited almost entirely to a single neighborhood on the 
southern border of the city, occupied by an unsanitary foreign population, 
whose water supply was from shallow wells, containing only water that 
had filtered from the surface soil. 

Another important predisposing influence is high temperature. With 
the exception of the epidemic in New Orleans, which commenced in De- 
cember, 1848, and prevailed very severely through that and the next suc- 
ceeding month, all the cholera epidemics in this country of which I have 
any knowledge, have occurred not only in the warm season of the year, 
but in seasons the average temperature of which was above the mean for 
a series of years. But the occurrence of the disease in New Orleans in 
December, 1848, constituted no exception to its prevalence during high 
temperature, for the records show that at the time, the temperature ranged 
from 24° to 29° C. (75° to 85° F.) coincident with a still, damp, and very 
impure atmosphere. 

As further illustrating the effects of temperature, I may remind you 
that the cholera was brought on board of an emigrant ship, into the har- 
bor of New York, during the same month of December in which it devel- 
oped so rapidly in New Orleans. And although the ship and its living 
cargo were detained in the quarantine, yet many of the passengers es- 
caped to the city, and a few of the number were found sick with the dis- 
ease in the city. But in New York, at that time, the temperature was as 
low as the average for winter in that latitude, and became still colder 
during the succeeding month. Consequently the disease wholly failed to 
develop in the city, and in a few weeks disappeared from the quarantine 

* For details concerning the epidemics from 1848-9 to 1854, see reports in the Transactions of the 
American Medical Association. Volumes II, III, IV. V, VI. Also a volume on Epidemic Cholera, 
h l ?„-, ■ ve \ nh Reese, M. I)., of New York. For the influence of local causes on the epidemic 
ot 1866 in Chicago, see Chicago Medical Examiner, Volume VIII, p. 637 to 658. 



664 EPIDEMIC CHOLERA. 

Again, the development and severe prevalence of the disease in Egypt 
during the past summer (1883), occurred directly under the coincident 
influence of high temperature, with extreme contamination of both air and 
water from decomposing animal matter, constituting a combination of 
local circumstances closely analogous to ihose accompanying the gathering 
of pilgrims at Mecca and other places in India. These considerations lead 
directly to the important etiological question, whether any combination of 
the predisposing influences I have named, is capable of giving rise to the 
disease, or must there be present in addition a specific cholera poison, or 
organic germ, derived from some other source, while the predisposing in- 
fluences only serve to increase its development or propagation and inten- 
sify its activity? The latter has been the popular doctrine in the profes- 
sion for the last twenty years. A large proportion of the more recent 
writers not only claim that the disease arises from a specific poison or 
infection, but also that such infection consists of organic germs or micro- 
phytes, developed in the blood and intestinal discharges of those suffering 
from the active symptoms of the disease. 

Those who advocate this view of the efficient cause of cholera pretty 
generally regard the same as originating in the valley of the Ganges, and 
as extending to other countries only by the transportation of the infectious 
microphyte from its native place in Asia. It was this idea that caused the 
disease to be so generally called Asiatic cholera. Of those who regard 
the disease as originating solely in Asia, one part regard the cause as a 
true contagium vivum capable of propagating the disease from person to 
person, like that of variola, while a much greater number regard the 
active cause as an infectious microphyte generated outside of the human 
system, but capable of propagation in the alimentary canal and the serous 
discharges therefrom. And by many it is supposed that the spread of the 
disease from place to place, or from one country to another, is effected 
chiefly through the agency of the cholera dejections in communicating 
the infectious principle or agent to the soil, water and atmosphere where- 
ever such dejections are carried. Many microscopic investigttions have 
resulted in discovering bacteria or microphytes in the evacuations during 
the progress of cases of epidemic cholera, more especially when the exam- 
inations are made after the discharges have been kept in a warm atmos- 
phere from eighteen to twenty-four hours. 

But hardly any two of the investigators agree as to the special micro- 
phytes peculiar to the cholera cases, and none of them have satisfactorily 
demonstrated their causative influence. During the prevalence of the 
disease in this city in 1866 ana again in 1873, I subjected many speci- 
mens of cholera discharges to careful microscopic examinations both imme- 
diately after they were voided and at short intervals for three succeeding 
days. In the examination of specimens just voided, very few microphytic 
formations of any variety could be detected, but after twelve or eighteen 
hours they became more numerous, and they continued to multiply dur- 
ing the three days they were kept for observation. On extending my ex- 
aminations, however, to the thin or serous discharges of simple cholera 
morbus and those of the "summer complaint" or common diarrhoea of 
young children, I obtained results so nearly identical that I could not 
maintain any line of distinction between them. I did not abandon the 
search until I became satisfied that there were no organic germs or bac- 
terial forms in the discharges during epidemic cholera, that were not also 
found in the dejections of cholera morbus, summer diarrhoea, and all other 
thin discharges from the mucous membranes, provided the specimens were 
all treated alike. Whether the several commissions that were organized 



CLINICAL HISTORY. 6G5 

under the directions of Koch, Pasteur and others, and sent out during the 
past summer to investigate the severe epidemic of cholera in E^ypt, have 
male any new or important discoveries can not be known until their re- 
ports are received and critically examined. It must be acknowledged, 
therefore, that up to the preseut time the efficient or specific cause of epi- 
demic cholera, if such cause exists, is unknown. That the prevalence of 
the disease in any given locality is mainly dependent upon the local 
conditions of temperature and organic impurities present in tli2 soil, water, 
and atmosphere, coupled with the personal hygiene of the inhabitants, is 
proved by the whole past history of the disease. My own clinical obser- 
vations in seven seasons of cholera prevalence, have afforded the strongest 
evidence that the disease is not propagated by personal contagion, that is, 
not directly communicable from person to person. AVhether the general 
and local conditions to which I have alluded as favoring the development 
and spread of cholera, when strongly concentrated, are capable of directly 
producing the disease, or whether this indirectly develops a specific infec- 
tious miasm or microphyte that like other infections is capable of being 
carried in clothing, or confined air, from one locality or country to 
another, and of being propagated whenever it meets favorable local con- 
ditions, are questions by no means satisfactorily settled. By a large ma- 
jority of writers of the present day the last question is answered in the 
affirmative. 

And some, like Dr. J. C. Peters of New York, have given us elaborate 
and ingenious maps, designed to show the origin of each epidemic, in its 
supposed Asiatic home, and its spread by transported infection from place 
to place on both continents. But there are so many gaps in the lines, 
filled by suppositions or the imagination of the writers, as to render them 
of little scientific value. 

Another circumstance strongly supporting the idea that the essential 
cause or causes of the disease originate in the locality where the disease 
prevails, instea I of having been imported from some other place, consists 
in the fact that in almost every epidemic season, isolated cases of a 
well marked character occur in different streets or neighborhoods, and 
gradually increase in number for some time before the arrival of the sup- 
posed infection from any other source. Thus Dr. Fenner and others in 
active practice at the time, record the fact that cholera diarrhoea and some 
cases presenting all the characteristics of cholera occurred in New Orleans, 
in December, 1848, before the ship which is credited with having brought 
the infection had reached within five hundred miles of that port. And 
the same has been true in reference to the first cases occurring at the be- 
ginning of every cholera epidemic in Chicago since 1850. 

Symptoms and Clinical History. — In a very large proportion of the 
cases o- cholera, the more active symptoms are preceded oy a moderate se- 
rous diarrhoea from one to five or'six days. The discharges" during this stage 
usually average three or four in the twenty-four hours; are very thin and 
voided without pain or effort, but are accompanied by a cool and pale 
condition of the cutaneous surface and a general feeling of weakness. 
After the continuance of this apparently mild diarrhoea one or more days, 
the more active symptoms are somewhat suddenly ushered in by an unus- 
ual feeling of weakness coupled with an active rumbling or peristaltic 
motion of the bowels quickly followed by a very copious watery evacu- 
ation; and frequently before this is finished an active paroxysm of vomit- 
ing supervenes. This finished, the patient lies down under a feeling of 
languor and exhaustion, with general paleness of the surface, a soft, weak 
and slightly accelerated pulse, respiration nearly natural, temperature 



66Q EPIDEMIC CHOLERA. 

natural or slightly below, urinary secretion diminished, and mouth deficient 
in moisture with some thirst. In the great majority of cases this sudden 
development of the active stage takes place during the last half of the 
night or before ten o'clock in the morning. 

In cases of average severity, the paroxysms of active vomiting and 
purging continue to recur at intervals varying from ten to thirty 
minutes, the discharges from the bowels being copious in quantity and 
having the appearance of turbid water, or that in which rice has been mac- 
erated. After the first two or three passages there is seldom any appear- 
ance of the coloring matter of bile in the evacuations either from the stom- 
ach or bowels, and the urinary secretion is much diminished, and in some 
cases, suppressed. 

Soon after the commencement of active vomiting and purging, severe 
cramps are felt, usually in the muscles of the calf of the leg first, and as 
the continuance of copious evacuations rapidly diminishes the relative pro- 
portion of the aqueous and saline elements of the blood, the cramps extend 
to the thighs, arms and muscles of the chest and abdomen, adding very 
much to the suffering of the patient. In the mean time the countenance 
and whole surface has shrunken, the eyes sunken in the sockets, the lips 
pale and thin, the extremities cold and bluish from the lessening of the 
circulation in the capillaries, the pulse frequent and weak, the mouth dry 
with intense craving for cold water, and the voice husky and feeble. 
After the first hour the skin becomes bathed in perspiration, which, added 
to the copious gastric and intestinal discharges, still more rapidly exhausts 
the blood of its water, until at the end of from three to six hours it becomes 
too thick to circulate through the smaller vesseis, the pulse disappears 
from the wrist, the intestinal discharges become in voluntas, all natural 
glandular secretions are suppressed, and the patient enters the stage of 
complete collapse. In this stage he may linger from one to five or six 
hours, presenting a cold, wet and shrunken state of the surface and 
extremities. The mind is dull, the eyeballs turned upward and eyelids only 
partially closed and the voice suppressed. He no longer vomits, but still 
has an occasional small involuntary discharge from the bowels with an 
occasional muscular cramp, and at length the chin drops, the breathing 
becomes irregular, the heart beats unsteady, and finally all the phenomena of 
life cease. Such are the prominent symptoms, and such the usual progress 
of attacks of epidemic cholera, when sufficiently severe to reach a direct 
fatal termination. 

The time occupied by the stage of active vomiting, purging, and crimps 
varies from three to twelve hours; that of collapse from one to six hours, 
in most of the fatal cases. In the midst of severe epidemics, however, 
you will meet with a few cases in which the violence of the cramps and 
copiousness of the evacuations bring on collapse and death in five or six 
hours. In the epidemic of 1854, in this city, I saw a case in the person 
of a Scandinavian laborer who went to his usual work in a lumber yard 
after breakfast apparently well. After continuing his work about an hour 
he became so weak that he was carried home on a dray, went to the water- 
closet and had one very large watery evacuation from the bowels and one 
turn of vomiting; returned to his room, sat long enough to smoke his pipe, 
took to his bed, became rapidly cold, bluish, shrunken, and with only 
slight cramps in his legs, passed into complete collapse and died in less 
than six hours from the time of first complaining. On the other hand a 
large proportion of the cases of cholera in every epidemic run a milder 
course than I have described and tend toward recovery. 

After from one to three or four days of premonitory diarrhoea, the active 



ANATOMICAL CHANGES. GG7 

stage is ushered in by vomiting and purging of a serous or rice water 
fluid, soon followed by muscular cramps, small weak pulse, cool and 
shrunken condition of the extremities, extreme thirst and dryness of the 
mouth, with weak or husky voice, and little or no sweating. When these 
active symptoms have continued from three to six hours, greatly diminish- 
ing the relative proportion of the water in the blood and bringing the 
patient to the verge of collapse, they begin to abate. The intervals 
between the passages from the bowels and also between the acts of vom- 
iting, become longer, the quantity passed at each time less, and in two or 
three hours more the vomiting and cramps cease, the pulse becomes slow- 
er and fuller, warmth returns to the extremities, the craving for drink 
diminishes, and the patient is inclined to sleep. In many cases after a 
few hours rest it is found that the renal secretion is more free, the mouth 
moist, and when the bowels move the passage is only semi-fluid and tinged 
with the coloring matter of bile; in a word, that the secretory functions 
generally have been restored and the patient fairly entered upon the stage 
of convalescence. Under rest and a mild diet, such cases rapidly recover 
their usual health and strength. You will meet, however, at the bedside, 
a considerable number of cases one grade more severe than those just 
described. The stage of active vomiting, purging, cramps, etc., though 
protracted and severe, will nevertheless cease before inducing complete 
collapse; but instead of passing directly into convalescence, the mind 
becomes dull or drowsy, the face suffused with redness, the lips and mouth 
remain dry, the urine scanty, and the extremities warm with more or less 
congestion of the skin, constituting a moderate general febrile reaction. 
This moderate grade of fever, accompanied by sufficient irritability of the 
stomach and bowels to cause an occasional vomiting, and three or four 
thin, gray or reddish brown passages in the twenty-four hours, may con- 
tinue from five to nine days, during which the assemblage of symptoms 
closely simulate those of enteric typhoid fever. In the majority of cases 
this secondary fever terminates in the gradual establishment of conva- 
lescence, but in some a low grade of inflammatory action is established in 
the mucous membranes, which causes the evacuations to continue with 
inability to retain and assimilate nourishment, and a fatal degree of 
exhaustion supervenes. 

You have thus three grades of active cholera attacks; the first, which 
runs its course in from six to eighteen hours, and ends in actual conva- 
lescence; the second, in which trie active stage is more severe, but stops 
short of inducing full collapse, and is followed by o.ie or two weeks of 
secondary fever; and third, those cases in which the active stage is so 
severe and the discharges so copious as to cause direct and generally fatal 
collapse. 

Anatomical Changes. — During the epidemic outbreaks of cholera in 
this country in 1849 and the five or six succeeding years, many very thorough 
post-mortem examinations were made, and the changes in the solids and 
fluids of the body were studied with much care. During the epidemic 
of 1849 in Boston, thirty-three autopsies were made, twelve on males and 
twenty-one on females. The ages of those examined varied from ten to 
sixty years, though a large majority were of adult age. The brain and its 
membranes were pretty uniformly reported natural. In a few cases slight 
serous effusions existed in the ventricles and on the surface of the mem- 
branes, and in fifteen of the cases the arachnoid surface covering the pos- 
terior part of hemispheres was covered with a thin layer of "dark, thick, 
bloody fluid," which was supposed to have transuded after death. The 
only unnatural appearances in the chest were an unusually dry and 



663 EPIDEMIC CHOLERA. 

shrunken condition of the pleura and pericardium. The lungs showed 
only slight indications of congestion in a few of the cases. The right 
cavities of the heart were not distended with blood, but in fourteen of the 
cases spots of epchymosis were found beneath the endocardium and 
sometimes in the pericardium. In the abdominal cavity, the peritoneum 
was found covered with a thin layer of opaline secretion or exudation, 
giving it a moist and sticky feel. The liver and spleen were contracted 
and contained less blood in their vessels than natural. The kidneys ap- 
peared nearly natural, in a few of the cases a little flaccid, but the mucous 
membrane lining the bladder and vagina was, in nearly all the cases, 
covered with a thick layer of fluid of a creamy consistence, while the 
bladder itself was contracted and empty of the urine. The contents of the 
alimentary canal varied much in consistence and color in different cases, 
but in most of them they were thin, yellowish-white or like soapy water, 
and contained both albumen and the coloring matter of bile. The micro- 
scope revealed an abundance of columnar epithelium and detached cells. 
The mucous membrane lining the stomach and intestines was generally 
pale, or natural in color, with no appearance of inflammatory congestion or 
general redness of the surface. The blood in the cavities of the heart and 
large vessels coagulated less readily and firmly than natural, and in fifteen 
of the cases the serum was distinctly thicker or more viscid than that of 
healthy blood. The rigor mortis and post-mortem contractions existed in 
all the cases.* 

During the same year, while the cholera was prevailing in Philadelphia, 
a committee appointed by the College of Physicians made still further 
investigations concerning the condition of the intestines in this disease. 
Dr. John Neill first filled the vessels with a fine injection colored with 
vermillion, and then subjected the mucous membrane to careful micro- 
scopic examination. The epithelial layer of the mucous membrane was 
found in all the specimens examined, "either entirely removed, or adher- 
ing loosely, as a pulpy layer mixed with mucus or an albuminal substance." 
The villi were also denuded of the epithelium but otherwise unchanged, 
and the capillary vessels unbroken. \ 

According to the investigations of Dr. C. Schmidt, the blood usually 
reaches its greatest degree of concentration from the rapid drain of the 
water in the discharges, during the first twenty-four to thirty-six hours 
after the commencement of active symptoms, when the proportion of solid 
constituents was found from one to one and a half times greater than 
natural. The increase consists chiefly of the corpuscular elements, extrac- 
tive matter, and the phosphatic salts. 

You must keep in mind the fact that the changes I have thus far de- 
scribed are such as are found in cases in which death resulted during col- 
lapse from the active stage of the disease. 

When death has been postponed until after reaction and the secondary 
fever, the autopsy will generally show more indications of inflammatory 
processes, more especially in the alimentary canal. 

In such cases there is more general redness of the mucous membrane 
of the ilium, with an increase of the lymphoid cells and slight tumefaction 
of thb glands of Peyer and Brunner. Numerous superficial follicular 
ulcers are also seen in parts that had been most denuded of epithelium in 
the past stage. In many of these cases the mesenteric glands are mod- 
erately enlarged with some degeneration of structure. The kidneys are 

* See "Report on the Cholera in Boston in 1849," published bv the authorities of that city. 
tSee Transact ons of he American Medical Association, Vol III, pp. 75-6. Also Transactions of 
the College of Physicians of Philadelphia, Dec. 4, 1&49. 



DIAGNOSIS. 669 

found more congested and tumefied, with noticeable fatty degeneration of 
(he tubular epithelium. In these cases also, the spleen, liver, lungs, and 
Serous membranes in the chest have lost the shrunken and dry condition 
they present when death results directly from collapse, and may even 
show some degree of congestion and traces of parenchymatous degener- 
ation. The only item of importance which has been added to our knowl- 
edge of the anatomical changes revealed by a study of the conditions 
found after death from epidemic cholera, since 1849, relates to the alleged 
finding of an organic germ or microphyte in the cholera evacuations 
which is represented as the special infectious agent or cause of the disease. 
Drs. Pettenkoffer, Snow of London, and others adopted the theory that 
the microphytes multiplying in the mucous membrane of the alimentary 
canal during the incubative stage of the cholera were discharged in large 
numbers with the evacuations in the subsequent active stage and were 
capable of impregnating the water in the soil, or adhering to damp 
clothing, and by undergoing further development out of the body 
through the agency of heat, moisture and decomposable organic matter, 
they become active and efficient agents in spreading the disease. That 
there are plenty of bacterial forms in the intestinal discharges during the 
active stage of cholera, is easily demonstrated by microscopic examination. 
During the epidemic in this city, 1866, I took many specimens from the 
discharges of my patients as soon as voided, and speedily subjected them 
to careful microscopic examination. Several of the specimens I kept 
from three to six days, repeating the examinations morning and evening. 
The bacterial formations were always few and very small at the first ex- 
amination, but they developed rapidly both in size and number by keep- 
ing. There were plainly several varieties of these organic germs, but the 
ordinary spherical bacteria and vibrios were much the most numerous. 
After making a thorough study of these specimens, I extended my exam- 
inations to the thin evacuations in ordinary cholera morbus, cholera infan- 
tum, and the simple summer diarrhoea of infants. By this means I soon 
learned that every variety of organic germ or microphyte that I had seen 
in the evacuations from my cholera patients, was equally visible in any 
serous evacuation from the alimentary canal when treated and examined 
in the same manner. The correctness of the results of these examination s 
has been confirmed by the subsequent observations of many others. I am 
justified therefore in stating that there are no organic germs peculiar to the 
intestinal evacuations in epidemic cholera, and consequently no founda- 
tion for the theory that the disease is propagated by specific germs from 
that source.* 

Diagnosis. — The only diseases from which cases of epidemic cholera 

* The latest information on this subject, is from Dr Koch, chief of the German Scientific Commis- 
sion sent to investigate the na*ure and cause* of the severe epidemic of cholera in Esypt. during 
the past summer, 1883. He says after examining the products from twelve cholera pati. nts and ten 
cadavers dead from the disease in Alexandria, that "no organized infective material could be dem- 
onstrated in the blood, or in those organs which, in the case of other infective diseases, are usu- 
ally the seat of micro-pa asites, viz.: the lungs, spleen, liver and kidneys. ***** The con- 
tents of the bowels and the dejections of the cholera patients contained extraordina'y quantities 
of micro-organisms belonging to the most differenc varieties, none of which appeared in prepon- 
derating proportion. There was also an absence of other indications of a relationship to the dis- 
ease-process." See Maryland itfedical Journal for Nov. 10, 18S3. While thus conceding that no 
micro-organisms peculiar to cholera were found either in the blood, the viscera, or the cholera de- 
jections, the report from Dr. Koch claims the discovery of a bacillus or rod-stniped microphyte in 
the mucous membrane of the lower half of the ilium, which had penetrated the follicular glands 
behind the epithelium, and proliferated between it and the basement numbrane of the gland. 
These bacilli were also seen in the villi and in some deeper parts of the membrane. He acknowl- 
edges, however, that "putrefaction is able to produce in the intestine exactly similar bacterial 
growths." And as all his efforts to produce cholera in a variety of animals by feeding or inoculat- 
ing them with these intestinal bacilli after isolation and cultivation, or by giving them fresh 
specimens of the intestine itself, entirely failed, we are yet without any positive evidence of the ex- 
istence of a micro-organism peculiar to, and causative of, epidemic cholera. 



G70 EPIDEMIC CHOLERA. 

need to be differentiated are sporadic cholera morbus and the choleraic 
and algid varieties of pernicious intermittents. From cases of cholera 
morbus, the epidemic disease differs, first, in very generally having a pre- 
monitory stage of painless diarrhoea from one to four or more days before 
the more active cholera symptoms commence, and second, in the more gen- 
eral suspension of normal secretory processes, and the earlier and more 
severe development of muscular cramps in a large part of the voluntary 
muscles. The failure of the voice and shrinking of the surface, is also 
much more marked than in cholera morbus. Yet I have repeatedly seen 
cases of sporadic cholera morbus, the symptoms of which so closely simu- 
lated those of well marked epidemic cholera, that had they occurred during 
the prevalence of an epidemic, they would have been regarded as typical 
cases of the last named disease. The known presence or absence of an 
epidemic influence, will, therefore, aid you much in determining your 
diagnosis in particular cases. From those cases of pernicious intermittent 
or malarious fever characterized by severe vomiting, purging and rapid 
prostration of all the processes and functions of life, cases of true cholera 
are to be distinguished by the preceding stage of cholerine or simple 
diarrhoea, the absence of rigors or a distinct chill at the commencement 
of active symptoms, the presence of more general and severe muscular 
cramps, and the co-existence of a recognized epidemic cholera influence. 
There is sufficient resemblance, however, between the active phenomena 
of a paroxysm of a pernicious choleraic intermittent and the active stage 
of cholera, to render it difficult for a practitioner who may see his patient 
for the first time in the midst of the paroxysm, to distinguish the one 
from the other by the symptoms. So true is this, that whenever cholera 
epidemics have invaded strongly malarious localities, the earlier cases 
have very often been regarded as malignant attacks of malarious fever; 
and some physicians of eminence have regarded the cholera itself, as 
only another phase of the more malignant effects of the same cause that 
produces the more common types of periodical fever. Some countenance 
is given to this idea by the fact that cholera epidemics have generally 
extended much more readily into malarious country districts, than into 
those destitute of that influence. But the differences in the phenomena 
of the initial stages, and still more in the anatomical changes as revealed 
by autopsies, as well as in the sequelae, are sufficient to establish the essen- 
tially distinct and independent character of the epidemic cholera. 

Prognosis. — If you exclude from the statistics of epidemic cholera all 
cases of cholera diarrhoea, and retain only such cases as develop active 
vomiting, purging of rice water character, and some cramps, you will 
always find a high ratio of mortality. Adopting this rule, and taking 
most of their statistics from cholera hospitals, nearly all recent writers 
place the mortality from this disease at from thirty to fifty per cent. This, 
however, gives an exaggerated idea of the fatality of the disease. But 
few cases of cholera are taken to a hospital until after the active symp- 
toms of the disease have commenced, and from the rapid progress of the 
disease, a large proportion of them will have passed the stage most favor- 
able for successful treatment before they arrive. To illustrate this fact I 
need only refer you to the details of admission to the special hospitals in 
the large cities of our country during the epidemic of 1849. For instance 
in five hospitals of this class in Philadelphia there were admitted an ag- 
gregate of 236 cases, of whom forty-nine or more than one- fifth were in 
complete collapse at the time of admission, and all died. Nineteen more 
were in partial collapse, of whom six died. While of the 168 admitted be- 
fore direct symptoms of collapse had supervened only eight died. The 



PROGNOSIS. 67 1 

late Dr. D. Francis Condie of Philadelphia, who had charge of the South- 
wark cholera hospital in 1849, and had also had ample opportunities for 
treating the disease during the epidemic of 1832, makes the following 
statement which has an important bearing on the question before us. 
"From the official position which I held in 1832 and 1840, I had a very 
Urge Held afforded for treating the disease. Now, in 1849, the percent- 
age of mortality in all the cases of cholera treated by me in the Southern 
hospital, was ten per cent, and in all the cases treated by me in private 
practice — that is in the patient's own dwelling — rather more than four 
per cent. The cases referred to were all genuine, fully formed attacks of 
epidemic cholera. If I had included all cases treated by me of cholerine, 
the percentage in hospital practice would have been reduced to seven, and 
in private practice to less than two." * 

My own clinical experience derived from an active and extensive 
practice in the cholera epidemic of 1849 in New York City, and in the 
epidemics of 1850, '51, '52, '54 and 1866 in Chicago, fully confirms the 
statements of Dr. Condie in relation to the ratio of mortality, both in 
regard to the cholerine and the fully formed attacks of epidemic cholera. 
It will be apparent to you, therefore, that if the cases of serous diarrhoea, 
technically called cholerine, are to be included in the statistics giving the 
whole number of cholera attacks in any given epidemic, then it must be 
conceded that there is a tendency in the milder cases to spontaneous 
recovery, and that under good treatment in private practice the per- 
centage of mortality resulting from all classes of cases will not exceed 
eight or ten per cent. But if all the mild cases are excluded as cholerine, 
and only such are included in the statistics as have taken on the more 
violent symptoms of the active stage, the mortality under the most judi- 
cious practice will range from ten to twenty-five per cent; and in hospi- 
tals where from one-fifth to one-third of the whole number are already in 
complete collapse when admitted, the ratio of deaths may be increased to 
fifty or sixty per cent. 



LECTURE LXIV. 



Epidemic Cholera Continued— Its Treatment and Prophylaxis. 

GENTLEMEN: Whatever may be the specific or efficient cause, or 
combination of causes, which produces epidemic cholera, the symp- 
toms and clinical history show that the prominent pathological condi- 
tions are, a general impairment of that elementary propertv of the 
tissues called vital affinity, by which both the tonicity of the tissues and 
the natural molecular movements concerned in the processes of nutrition 
and secretion are diminished; an equal impairment of the functions of the 
vaso-motor nervous system, more especially that part of it connected with 
the vessels of the mucous membrane of the alimentary canal, and coinci- 
deutly an increased excitability of the same membrane. It is this coin- 
cidence of impaired tonicity, vaso-motor paralysis, and increased suscepti- 
ve Report on Practical Medicine and Epidemics in the Transactions of the American Medical 
Association, Vol. Ill, p. 112, 1850. 



G72 EPIDEMIC CHOLERA. 

bility, that starts the undue exudation of the serous elements of the blood 
from the whole* extent of the alimentary mucous membrane, carrying 
much of the epithelial layer with it, and furnishing the material for the 
copious discharges characteristic of the disease. To these primary and 
essential pathological conditions are added, as the disease progresses, the 
rapid thickening of the whole mass of the blood, the shrinking of the 
tissues, the muscular cramps, and finally the failure of oxygenation, deear- 
bonization and circulation, constituting complete collapse. Or, if the 
morbid changes stop short of this, congestions take place in those portions 
of the mucous membrane most denuded of epithelium, followed by a low 
grade of inflammatory action, and secondary fever, of more or less danger 
to the patient. If these v.ews concerning both the primary and second- 
ary pathological conditions present in an attack of cholera are correct, 
they readily suggest certain rational and important objects to be accom- 
plished in the treatment of each successive stage of the disease. These 
objects are, first, to restore the general tonicity of the tissues, to increase 
the activity of the internal vaso-motor influence, and lessen the undue 
excitability of the mucous membranes, in the early stage of the disease. 
Accomplishing these objects fully cuts short the disease and renders the 
further use of medicines unnecessary. Failing in this, the next leading 
object is to limit the serous exudation to such an extent, at least, as to 
prevent extreme thickening of the blood, and to maintain the more 
important secretory and eliminative functions in a state of activity. Still 
later, however, when the water and saline elements of the blood are 
already greatly diminished, the renal and other secretions nearly suppressed 
and the thickened and imperfectly oxygenated blood fast stagnating in 
the capillaries of the shrunken tissues, it becomes an object of paramount 
importance to replenish and dilute the blood by restoring, as far as possi- 
ble, its wasted elements, and at the same time, to maintain the sensibility 
and action of the nervous centers of organic life 

Finally, if your patient passes by the immediate dangers of collapse and 
a secondary fever is developed, you must combat the local intestinal, 
renal, or other hypergemias and sustain general nutrition on the same 
principles and by substantially the same means that I pointed out for the 
management of the more advanced stage of enteric typhoid fever. Such, 
gentlemen, are the objects clearly before you for accomplishment in the 
different stages of a cholera attack, from the initial diarrhoea to the end 
of the secondary fever. And I need not add that on the promptness 
with which you recognize these objects, and the skill you display in 
selecting and applying the proper means for their accomplishment, will 
depend your success in the treatment of the disease. Neither is it neces- 
sary for me to assure you that no one remedy is calculated to meet fully 
the indications at any stage of the disease, much less at all stages. All 
acute general diseases present complex pathological conditions which 
change in their relations as these diseases progress through their successive 
stages either to the recovery or death of the patient. To attain the high- 
est degree of success, therefore, you must so combine remedies as to meet 
the complex pathological elements, and so vary them as the disease pro- 
gresses, as to preserve the accuracy of their adjustment to the changing 
conditions of the disease. The numerous statistics you find in your books 
in regard to the relative value of opium, alcoholic liquids, calomel, 
emetics, saline evacuants, bleeding, etc., are of no actual value simply 
because they are not accompanied by an accurate statement of the stage 
of the disease, the condition of the patient, and the coincident use of other 
remedies, at the time any one of the remedies named in the tables was 
being used. 



TREATMENT. 



673 



The most favorable time for accomplishing the first objects I have 
Darned, is, the stage of premonitory diarrhoea and the first one or two 
hours after the active cholera symptoms have supervened. During the 
first of these periods, one of the most reliable combinations I have used, 



is the following: 



Acidi Sulphurici Aromatici 


15.0 c. c. 


3iv 


Magnesiae Sulphatis 


15.0 grams 


3iv 


Tincture Opii 


15.0 c. c. 


3iv 


Elixer Simplicis 


30.0 c. c. 


Si. 


Aquae 


60.0 c. c. 


§ii 



Mix. Give to an adult four cubic centimeters (fl. 3i) in a little addi- 
tional water every three, four or six hours according to the frequency of 
the evacuations, and keep the patient at rest. During each of the cholera 
epidemics in this city since 1849 I have used this prescription in a large 
number of cases of cholerine with the most satisfactory results. The 
sulphuric acid and aromatics furnish the necessary tonic influence to 
the tissues and a mildly stimulant effect to the vaso-motor nerves, 
while the opiate effectually allays the morbid excitability of the mucous 
membranes. I usually repeat the dose at the shorter intervals until the 
discharges have been prevented foi twenty-four hours, and then increase 
the interval until the passages are limited to one in twenty-four hours, 
and are natural in color and consistence. If malarial influences were prev- 
alent at the time, the intestinal discharges light colored, and the patient's 
tongue coated, I gave in addition to the foregoing prescription a pill or 
capsule containing sulphate of quinia, thirteen centigrams (gr. ii) and 
six centigrams (gr. i) of blue mass each morning and noon. 

Another combination which 1 have sometimes used as a substitute for 
the aromatic sulphuric acid mixture, and with good effect is the following: 

I£ Acidi Sulphurici Aromatici 
Tineturae Cinchonas Comp. 
Tincturae Nucis Vomicae 
Tincturae Opii Camphoratae 

Mix. Give an adult four cubic centimeters (fl. 3i) in a little sweetened 
water, every three, four or six hours until the bowels are regular. I might 
multiply formulae intended for the accomplishment of the same general 
purposes, but the two already given are sufficient to indicate the nature of 
the remedies needed to correct the morbid processes in the first or prelim- 
inary stage of the disease. 

When the active symptoms, vomiting, purging, and cramps, have com- 
menced, I direct the immediate application of strong mustard sinapisms 
over the epigastrium and nearly the whole length of the spine; keep the 
patient in a horizontal position with dry warmth to the extremities, and 
give internally every half hour three milligrams (gr. 1-20) of strychnine 
and eight or ten minims of oil of turpentine, rubbed up with gum arabic, 
sugar and mint water, in the form of an emulsion. Immediately after 
each paroxysm of vomiting I also give a powder containing sulphate of 
morphia fifteen milligrams (gr. ^), calomel, six centigrams (gr. i) and 
white sugar three decigrams (gr. v) rubbed together, and follow it by a 
small piece of ice instead of water or any other kind of drink. I mean to 
be understood literally when I say immediately after each paroxysm of 
vomiting, for the stomach cannot maintain a continuous effort to eject its 
43 



15.0 c. c. 


3jy 


60.0 c. c. 


fii 


15.0 c. c. 


3iv 


60.0 c. c. 


Sii 



G74 EPIDEMIC CHOLERA. 

contents. Consequently if the powder is swallowed immediately after the 
contractile power of the stomach has been exhausted by a paroxysm of 
vomiting, a little time will elapse before another paroxysm can take place, 
during which the morphine will gain some impression on the nervous sen- 
sibility, and the calomel on the capillaries of the mucous membrane. If 
you delay, however, as nearly all nurses and patients will desire to do 
after each act of vomiting, until the patient has "rested a few minutes," or 
the " stomach has settled a little," such delay will usually be just long 
enough for the muscular coat of the stomach to regain its contractility 
and its cavity to have gathered a fresh accumulation of effused serum, and 
is, therefore, all ready for another paroxysm. Then if you give the 
powder or anything else it will be promptly rejected by vomiting as soon 
as it is swallowed. At the same time that I direct the foregoing treat- 
ment by the mouth, I also direct three centigrams (gr. ^-) of acetate of mor- 
phia, and six decigrams (gr. x) of acetate of lead, dissolved in about 
sixty cubic centimeters (fl. ^ii) of water, to be used as a rectal enema, 
immediately after each intestinal evacuation. 

In a large proportion of the cases that have come under my care very 
soon after the commencement of the active cholera symptoms, the plan of 
treatment just detailed has begun to moderate the violence of the symp- 
toms in from two to three hours, and by continuing the same remedies at a 
little longer intervals, all active symptoms have ceased before the patient 
reached a dangerous degree of prostration. In the epidemic of 1866, I 
used in many cases the ordinary carbolic acid mixture in doses for adults 
of four cubic centimeters (fl. 3i) after each act of vomiting instead of 
the powder of morphine and calomel.* During all this early part 
of the active stage of the disease, the patients were kept as constantly 
in the recumbent position as possible, their craving for cold water 
satisfied by frequent small pieces of ice, held in the mouth long 
enough to smooth the edges and angles and then swallowed. But if, 
either from failure of the remedies or from neglect of treatment, the se- 
rous discharges have continued until the surface is much shrunken, the 
extremities bluish, the pulse feeble, and the sweating copious, indicating 
much diminution in the relative proportions of the water and salts of the 
blood ani consequent near approach of collapse, instead of continuing 
the remedies already mentioned, it is better to give at once a hypodermic 
injection of sulphate of morphia one centigram (gr. 1-6) and atropia 
one milligram (gr. 1-60), and endeavor to replenish the exhausted elements 
of the blood and maintain the susceptibility of the nervous and other 
structures by giving alternately, every fifteen or twenty minutes, fifteen 
cubic centimeters or a tablespoonful of strong infusion of coffee or tea, 
and of beef or chicken broth well salted with chloride of sodium or chlorate 
of potassium. If the first hypodermic injection does not promptly check 
the sweating, improve the pulse, and stop the vomiting, it may be repeat- 
ed in from half an hour to an hour. At this stage, when the blood has 
become too thick to circulate freely, and too imperfectly oxygenated to 
sustain either nerve sensibility or secretory action, the influence of the 
atropia over the vaso-motor nerves of the periphery by which further exu- 
dation from the skin may be checked, and of the coffee or tea (or their 
active principles, caffeine or theine) in directly increasing the general sus- 
ceptibilities, make them the most efficient agents we possess for resisting 
the further progress of the patient toward complete and fatal collapse. 
And when promptly resorted to in the stage indicated, in connection with 

* See pa^e 656. 



TREATMENT. 675 

the persevering use of small and frequently repeated doses of well salted 
animal broths to maintain the fluidity and oxygenation of the blood, they 
have produced better results than any other remedies I have used. As a 
rule, a strict horizontal position with dry warmth to the surface and ex- 
tremities should be maintained throughout the whole of the active stage 
of the disease. All wet applications, after the first mustard sinapisms, 
onlv increase evaporation and thereby help to reduce the temperature, 
already too low, and consequently should be avoided. Active and per- 
sistent frictions, so frequently resorted to, also do more harm than good by 
the agitation and weariness induced by them. The best way to lessen 
the cramps, is simply to seiz 5 the cramping muscles and hold them under 
firm pressure a few seconds until they relax. At the same stage of the 
disease in which I have suggested the use of hypodermic injections of 
morphine and atropia, advantage has been derived from two or three 
thorough applications over the whole cutaneous surface of a dilute mercu- 
rial ointment in which was incorporated a liberal quantity of pulverized 
gum camphor and cayenne pepper. This application was used quite ex- 
tensively in some of the cholera hospitals in New York City, during the 
epidemics of 1849 and 1854, and according to the reports with good effect. 

If the stage of actual collapse finally ensues, the chances of recovery 
under any treatment will be very small. They will be best promoted, 
however, by continued rest and the faithful administration in small and 
frequent doses of the coffee, tea, and well salted animal broths, in the 
same manner as I have already mentioned. Under such treatment, I 
have seen a few cases of well marked collapse from which the patients 
recovered. 

If, either before or after collapse, febrile reaction comes on, and a 
grade of secondary fever is established, accompanied by inflammatory 
congestion in the parts of the mucous membrane most denuded of its epi- 
thelium, it can be most successfully treated on the same principles and by 
the use of the same remedies, that I recommended in detail when speaking 
of the management of the second stage of enteric typhoid fever. I have 
now given you, in as few words as possible, the treatment for the several 
stages of cholera, in which I was induced to place much confidence, from 
an active personal experience in several epidemics. During that expe- 
rience, I either tried, or saw others try, a great variety of additional reme- 
dies. I have resorted to venesection, cupping, emetics of chloride of so- 
dium and mustard, camphor, saline evacuants, and astringents; and I have 
seen others use ice and salt to the surface, large doses of opium, quinine, 
calomel, alcoholic liquids, etc. In a few cases, characterized by unusually 
severe muscular cramps at the commencement of the active stage, I thought 
that thorough dry cupping over nearly the whole length of the spine af- 
forded some relief. In three or four similar cases, a moderate venesection 
afforded some temporary relief, but nothing permanent. In three or four 
cases the local effects of salt and mustard on the gastric membrane, 
coupled with the revulsive effect of free vomiting, appeared to promptly 
check the further progress of the disease; but in other cases it only hast- 
ened on the stage of exhaustion. In some neighborhoods where there was 
a strong coincident prevalence of malarious influence, the use of moderate 
doses of quinine by hypodermic injectio 1 produced some good. But from 
all my past opportunities for observation, I am fully satisfied that the 
liberal use of alcoholic liquids, and what are called heroic doses of medi- 
cines of any kind are injudicious and productive of much more harm than 
good, in the treatment of every stage of epidemic cholera. 

Complications and Sequela}. — The active stage of epidemic cholera is 



676 EPIDEMIC CHOLEEA. 

not often complicated by the co-existence of any other disease. And such 
attacks as end in convalescence without the supervention of secondary 
fever, usually allow of a rapid recovery. But when the active stage is 
followed by secondary fever, the inflammatory developments in the mu- 
cous membrane often affect that part lining the colon and rectum, caus- 
ing decided symptoms of dysentery. Cases of this kind are noticed more 
frequently toward the close of a summer epidemic of cholera, than at its 
beginning. When such cases do occur they are to be treated in the same 
manner as I directed when speaking to you of the asthenic grade of dys- 
entery under the head of inflammations of the alimentary canal. Per- 
haps the most important complication, which may continue also as a sequel, 
is such a degree of renal congestion as to cause the urine to be albumin- 
ous and very much diminished in quantity, or entirely suppressed. The 
secretion of urine is always much diminished during the active stage of 
cholera when the water of the blood is being actively drained through the 
bowels, but in most cases of favorable tendency, the secretion is resumed 
as soon as the intestinal discharges cease. When it is not, there soon 
follows more or less drowsiness, slight muscular twitchings, a soft, weak 
pulse, and a low temperature. If the suppression or extreme paucity of 
urine continues beyond twenty-four hours, the drowsiness generally deep- 
ens into unconsciousness or coma, with slow and irregular respiration, varia- 
ble pulse, cold extremities, and sometimes sweating with a urinous odor. 
Unless relief is obtained by a resumption of secretion some time during 
the second or third days, one or two momentary paroxyms of general 
spasm or muscular rigidity occur, followed speedily by entire failure of 
respiration and circulation, and consequently the death of the patient. 
The best way to obviate such a resuit, to re-establishing the renal secre- 
tion is to re -dilute the blood by giving small and frequent doses of milk 
whe} 7 , buttermilk or animal broths; sustain nerve sensibility and cardiac 
force by caffeine, and endeavor to directly excite increased renal secretion 
by giving as freely as the stomach will bear, an infusion of juniper berries, 
uva ursi and galium, holding in solution the acetate or nitrate of potassium. 
In one case that came under my observation during the cholera epidemic 
of 1866, recovery took place after complete suppression had continued 
three days, under the treatment just indicated. In another case in the 
same epidemic, complete suppression of urine took place during the latter 
part of the active stage and continued nearly five days, and yet recovered, 
the secretion being finally re-established while taking a powder containing 
nitrate of potassium, three decigrams (gr. v), and calomel, thirteen centi- 
grams (gr. ii), every two hours.* 

Prophylaxis. — According to the most generally accepted doctrines 
in regard to the origin, and spread or propagation of epidemic cholera, it 
originates in some part of India or southern Asia, and is carried to other 
countries by human intercourse, the infection being supposed capable of 
adhering to clothing or merchandise; of being retained in the holds of 
ships; and especially to be propagated in the intestinal discharges of 
cholera patients. It is true, all concede that there must be a high tem- 
perature and certain bad sanitary conditions in the places or countries to 
which the supposed infection is carried, or it will not propagate itself or 
develop any epidemic of the disease. If you accept the correctness of 
these views, it logically follows that your chief prophylactic measures 
must be efficient quarantines, including thorough vessel and immigrant 
inspection, to prevent the importation of the infection; immediate and 

* See Chicago Medical Examiner, Vol. VII, pp. 746-750, 1866. 



PKOPHYLAXIS. bu 

thorough disinfection or destruction of all the discharges and clothing of 
cholera patients, to arrest the progress of an epidemic after it has com- 
menced; and the enforcement of local cleanliness, ventilation and good 
water supply, for the purpose of removing the local conditions favorable 
for the propagation of the supposed infection. While the facts connected 
with the development of everv epidemic which has appeared in this coun- 
try are not capable of satisfactory explanation on the theory of imported 
infection, it is nevertheless a good rule to keep always in force such 
measures of inspection, isolation and quarantine as will prevent, as far as 
possible, the importation of all forms of disease and unsanitary materials. 
The theory that there is a specific cholera infection propagated chiefly in 
and by the cholera evacuations, is certainly unsupported by an adequate 
number of observed facts. Even the most learned and well equipped 
commissioners, who have visited Egypt for the special purpose of investi- 
gating the nature and causes of the severe cholera epidemic in that coun- 
try during the past summer, have been wholly unable to propagate the 
disease by using either the fresh dejections or the bacilli found in the 
iutestines after isolation and cultivation. Yet as all organic matter, sep- 
arated from the living body under a summer temperature, is capable of 
speedily undergoing such degenerative chinges as to evolve elements of 
a hurtful or dangerous quality, the serous discharges from cholera patients 
should be at once removed and so disinfected as to prevent further putre- 
faction or septic changes, as far as possible. But of all the prophylactic 
measures for preventing the spread of cholera, those which relate to the 
maintenance, for the community at large, of a pure atmosphere, a clean 
soil, and an adequate supply of good water, and for the individual or 
family, cleanliness of person and premises, good ventilation, wholesome 
food, and minds free from unreasonable fear and anxiety, are by far the 
most important. And there are these important advantages in keeping the 
minds -of any community strongly impressed with the protective value of 
strict sanitary measures and with the necessity for the removal or avoidance 
of all sources of local impurities of either air or water, that they all con- 
tribute in an equal degree to protect the community from a great variety 
of other and more common diseases. 

Of the protective measures of a personal character I enumerated free- 
dom from unreasonable fear and anxiety; to which should also be added 
exemption from excessive fatigue, and the avoidance of all alcoholic 
drinks, whether fermented or distilled; and the a.lherence to a plain ordi- 
nary diet, including a fair variety of vegetable and animal substances, 
such as agree best with the individual when no epidemic exists. 

Such members of the community as can not divest themselves of a cer- 
tain feeling of dread, fear or anxiety about their personal safety during 
an epidemic, had much better go early and directly to some place exempt 
from any liability to a prevalence of the disease; for all experience shows 
that such mental conditions very greatly increase the chances of being 
attacked. On the contrary, a cheerful, confident tone of mind resting on 
clear convictions of duty and right, and aided by habits of temperance 
and virtue, will do very much to shield the individual from an attack of 
cholera during an epidemic, even of the most severe and protracted char- 
acter. These remarks are as applicable to physicians as to the members 
of any other profession or calling in life. 



678 DROPSIES. 



LECTURE LXV 



Aqueous Fluxes from the Serous Membranes or Shut Sacs and Areolar Tissue: more generally 
called Dropsies. Their Varieties, Causes, Clinical History, and the General Principles governing 
their Treatment. 

GENTLEMEN: The serous membranes of the body, unlike the cuta- 
neous surface and the mucous membranes, are all shut sacs: and 
consequently, whenever serous fluid, or the watery element of the blood 
flows from these surfaces faster than it can un iergo natural absorption 
through the blood vessels, it accumulates, and causes more or less disten- 
sion of the sac itself. The same is true when the effusion or exudation 
of fluid takes place from the vessels of the areolar tissue or parenchyma 
of the organs. Accumulating faster than it can be absorbed, it fills up 
the tissue, causing it to be tumefied, or ce lematous, by having its inter- 
stitial spaces distended with the effused fluid. As remarked in the pre- 
vious lecture, when serous or watery fluid accumulates in any of these 
parts, it constitutes some form of what is familiarly styled dropsy. Par- 
ticular names are applied, according to the membrane or point of the body 
including the accumulated fluid. In a strict pathological sense all those 
cases included under this head of serous fluxes into the shut sacs of the 
body are symptoms of some co-existing and preceding disease, and do 
not constitute individual diseases. They are susceptible of division into 
two classes: one, in which the serous flow is the result of inflamrmtion 
of some grade in the membrane from which the effusion takes place. 
As you have learned, when considering the local inflammations of serous 
structures, one of the almost constant results occurring- in the progress 
of the inflammation was an effusion in the second stage of the inflam- 
mation. And in cases where the inflammatory action assumes more or 
less of a chronic form, the amount of effused fluid becomes sufficient 
to create full distension of the cavity of whatever membrane is in- 
volved, and to remain incapable of absorption after the inflammition pro- 
ducing it had disappeared. Aside from the existence of inflammation 
as a cause of serous flux from the membranes lining the cavities of the 
body, and the areolar or connective tissue of the different structures, the 
causes, that usually result in serous flux or dropsical accumulations, may 
be arranged into two classes: The first class consists iu the obstruction 
of the circulation in the vessels leading from the membrane from which 
the effusion takes place; as familiarly illustrated by those diseases of the 
liver which lead to obstruction of the circulation through the portal vessels 
distributed in the liver, causing undue fullness of the opposite distribution 
of the same vessel in the abdominal viscera. 

But the same rule will apply to all serous surfaces, wherever the vessels 
carrying the blood from the part are such that they are capable of being 
obstructed in any part of their course so as to increase the fullness of the 
vessels of the membrane. This fullness causes the watery element of 
the biood to exosmose or transude through the walls of the vessels to the 
cavity formed by the membrane. The same is true in regard to dropsi- 
cal accumulations in the connective tissues and parenchymatous struct- 
ures. Any obstruction in the course of the vessel, to the return of the 
blood from the part causes habitual overfullness of the capillaries, leads 
to exudation of the watery elements, filling up of the tissues, and consti- 
tutes what is usually called, oedema or anasarca. This is well illustrated 



VARIETIES. 679 

by the pressure of the gravid uterus upon the iliac veins in advanced 
pregnancy; often so far obstructing the return of blood from the lower 
extremities as to cause them to become largely infiltrated with drop- 
sical fluid, or cedematous. Tumors in the axilla will frequently produce 
the same effect, by pressure upon the veins returning the blood from the 
hand ami forearm, causing more or less serous infiltration into the tissue, 
making the hand and arm throughout cedematous. It is thus that we 
have a variety of impediments, which produce dropsical accumulations, 
either in the shut sacs, or in particular tissues, purely of a mechanical 
character, without any necessary alteration, either in the composition of 
the blood, or in the special pathological condition of the structures in- 
volved in the effusion. The other class of causes which are liable to pro- 
duce cedematous infiltration, or dropsical accumulations in the shut sacs, 
are such as produce impoverishment of the blood itself, causing the albu- 
men and red corpuscles of the blood, one or both, to become largely defi- 
cient or below the natural proportion in healthy blood. In proportion as 
these constituents are diminished below the natural standard, the blood 
becomes thinner and approaches more nearly to the consistence of water. 
It is a physiological law, that the smaller blood vessels and capillaries, hav- 
ing their walls adjusted to the circulation of fluid of a given consistence, 
whenever the blood is rendered more fluid, beyond a given limit, its vessels 
allow exudation or transudation of the watery element through their walls 
into the interstitial spaces of the tissues, and from the membranous sur- 
faces into the sacs of the membranes. 

Perhaps the most familiar illustration of this class of cases is found in 
those diseases of the kidney which give rise to the excretion of albumen of 
the blood with the urine, as in Bright's disease proper, and the different con- 
ditions grouped under the name of albuminuria. One of the constant 
tendencies of such cases is, by the progressive thinning of the blood from 
the removal of a large proportion of the albumen and consequent increase 
in the relative proportion of the water of the blood, to induce general 
exudation of that watery element from the smaller blood vessels into 
the areolar tissues of the body, first, and, as the impoverishment still 
goes on, ultimately into one or more of the serous sacs of the body. 
The same result maybe pro iuoed by excessive and repeated hemorrhages, 
by which both albumen and red corpuscles are reduced below their normal 
proportion in the blood. The continued action of malaria, as is well 
known, produces similar impairments particularly in reference to the red 
corpuscles, thereby greatly diminishing the viscidity of the blood and 
resulting in oedema, or dropsical effusion into the areolar sacs, in the 
more dependent parts first; and, as the impoverishment of the blood goes 
on, all the structures throughout become subject to ceiematous or drop- 
sical infiltrations. These illustrations are sufficient to show you, first, 
that all serous accumulations in the various shut sacs of the body and 
parenchyma of organs, are not only symptoms but results, and not dis- 
tinct diseases, although they may receive distinct names. They arise 
either from inflammation of the texture from which the effusion has taken 
place, or from the mechanical impediments to the return of blood through 
the vessels from the parts in which the effusion occurs, or third, from 
absolute thinning of the whole mass of the blood until it approximates in 
its consistence that of water itself. Such a condition is generally the 
result of the impoverishment of the red corpuscles, or of the albumen, or 
of both. The two first of these causes lead to circumscribed dropsical 
accumulations, by which I mean accumulations directly limited to a par- 
ticular serous cavity, or to some particular portion of the areolar tissue. 



G80 DROPSIES. 

♦ 

It will require only a moment's reflection on your part to see why these 
two classes of causes necessarily induce circumscribed or local dropsy. 
The first are inflammations directly of the part from which the effused fluid 
occurs and necessarily must be essentially local. The second, arising 
from obstruction to the return of blood through particular vessels, will 
affect only the parts to which these vessels are distributed, and con- 
sequently must be, primarily at least, local in the development of the drop- 
sical result. The vena porta, having distribution only in the abdominal 
viscera, in its obstruction leads only, primarily, to abdominal dropsical 
accumulations. The iliac veins returning the blood sent to the lower 
extremities when obstructed will lead only to dropsical or cedematous 
infiltration into those extremities and so of all other parts. But, on the 
other hand, dropsy that arises from the third class of causes, those which 
produce impoverishment of the blood itself, rendering it too thin to 
circulate freely through the smaller vessels without exosmose or trans- 
udation, are not local. Their first beginnings are always determined by 
the law of gravity. The dropsical accumulation showing itself first in 
the parts most dependent or most distant from the heart or central organ 
of the circulation. Consequently this form of dropsical effusion in all the 
earlier part of its progress is changed, by change of position. The 
patient in the horizontal position during the night presents in the morning 
indications of dropsical infiltration in the bloated condition of the coun- 
tenance, pufifiness under the eyes and not infrequently pitting along 
the surface of the trunk of the body. But on assuming the upright 
position in the morning and during the day, these appearances will leave 
the face and upper part of the trunk, while the feet, ankles and limbs, 
will perhaps become filled up, so that in the evening they will be largely 
swollen from the dropsical infiltration. But placed on a level with the 
body, this disappears in a great measure during the night. 

Those accumulations that result from alterations in the mass of the 
blood, are properly denominated general dropsy. Always pervading 
the areolar tissues first, in the parts most dependent and most remote 
from the central organs of the circulation, and as the case progresses, 
capable of increasing, step by step, until it permeates almost the en- 
tire structures of the bodv, before death takes place. The circum- 
stances to which I have alluded are important in enabling you to 
make a correct diagnosis in the cases that may come before you in the 
general field of practice. The first step in the diagnosis of any case 
that may present itself, will be, to determine, if possible, the morbid 
condition, or disease, which has been the cause of the dropsy. A 
simple examination of the patient exteriorly, will enable you to deter- 
mine readily whether the case is one of general dropsy, pervading the 
most dependent tissue prominently, and changing more or less by change 
of position, thus showing that it is influenced by the law of gravity, or 
whether it is confined to some particular portion of the body, or some 
particular cavity. If the first, it is general dropsy; if the second, it is 
circumscribed dropsy. In the first you are to look for the pathological 
condition giving rise to the dropsy, first, in alterations in the mass of 
the blood, and secondly, in the particular conditions which may have pro- 
duced such alteration in the blood. In the second, or cases of circum- 
scribed dropsy, it is comparatively easy to determine the disease or patho- 
logical condition which has given rise to the dropsical accumulation, by 
simply investigating as to the symptoms of inflammation in the part, 
or in the absence of any such symptoms, either present, or in the past 
history of the case, by searching for some mechanical impediment in the 



PROGNOSIS. 681 

course of the vessels leading from the part. On the other hand, in all 
cases of general dropsy resulting from impoverishment of the blood, you 
will most readily arrive at a correct discovery of the primary patholog- 
ical condition by examining carefully the physical signs connected with 
the heart, having reference especially to the existence of structural or 
valvular lesions, capable of obstructing mechanically, the flow of blood 
through the cavities or openings of that organ, and in case no evidence 
of disease is found there, your attention should be turned next to the 
urine, examining it carefully by the proper tests, and if no evidence of 
albumen is lbu id, or other condition of chat secretion which would ex- 
plain the occurrence of an excess in the relative proportion of the watery 
element of the blood, then your attention must be next turned directly 
to those causes of blood impoverishment to which I have already alluded; 
such as protracted malarious influences, repeated and copious hemor- 
rhages, or some one of those peculiar constitutional forms of disease, de- 
nominated leucocythaemia, pseudo-leucocythaamia, and pernicious anae- 
mia. In at least ninety-nine cases out of every hundred, however, the 
general drops}-, or rather the primary morbid condition which has led to 
it, will be found either in cardiac or renal disease, or in the action of ma- 
laria, or in copious and persistent losses of blood by hemorrhages. 

Prognosis. — [n the management of all cases of dropsy, the first object 
of importance is to arrive, as I have just stated, at a correct conclusion 
in regard to the pathological conditions which have led to the serous ac- 
cumulations. Having done this, you are enabled, generally, to determine 
with much accuracy how far the case admits of a cure, and how far tin 
patient can expect only palliation, or temporary relief. The dropsical 
difficulty, being only a symptom or result of some one of the pathological 
conditions to which I have alluded, if such condition, in any given 
case, is itself capable of being remedied, the removal of the dropsical ac- 
cumulation will generally follow. On the other hand, if the dropsical 
accumulation is the result of such organic or structural diseases as are 
themselves incurable, the only benefit that can be conferred upon the pa- 
tient will be the adoption of such measures as will temporarily diminish 
the dropsical accumulation, or in some measure retard the progress of the 
primary disease. Unfortunately, a large proportion of the cases of gen- 
eral dropsy depend upon organic disease of a permanent character, ei- 
ther in the heart or in the kidneys; while those cases that result from 
malarious influences, or from hemorrhages, are more frequently suscepti- 
ble of permanent relief. And yet hemorrhages sometimes arise from in- 
curable pathological conditions; such as cancerous or malignant growths, 
and hemorrhagic diatheses. 

In the circumscribed dropsies, the prognosis will also depend entirely 
upon the nature of the local pathological conditions which have given rise 
to the serous accumulations. The larger proportion of those which have 
resulted from direct inflammation in the part are curable, as you have 
already learned from the discussion of the treatment of inflammation in the 
different organs and structures of the body. Those cases of circumscribed 
dropsy that arise from changes in the important internal viscera, such 
as cirrhosis of the liver, being themselves permanent or incurable, the 
prognosis is necessarily unfavorable; although in many of them much can 
be done, both to palliate the patient's condition, and to prolong life. 
Where the effusion has arisen from pressure upon the blood vessels return- 
ing the blood from the part in which dropsy occurs, relief may often be 
obtained by removing the cause of the pressure. A gravid uterus in 
due time relieves itself, and removes pressure from the iliac vessels. 



6S2 DROPSIES. 

♦ 

Tumors, which may press upon the larger veins, as when developed in the 
axilla or in the groin, and sometimes in the abdomen, in such a way as to 
rest upon the iliac veins, or abdominal aorta, are not infrequently capa- 
ble of being removed by surgical operations. 

Treatment. — It is thus that treatment of all dropsy resolves itself 
primarily and largely into the adoption of such measures as are calculated 
to remove the various pathological conditions, which have given rise to 
the alterations in the blood, or that mechanically impede its circulation 
through different parts. Yet there is a large proportion of cases in which 
these pathological conditions can not be removed, and where the work of 
the physician is restricted to the effort to palliate the patient's condition by 
retarding the increase of the dropsical accumulations and sustaining the 
strength of the patient. It becomes therefore an important practical 
question at the bedside, how, in the more important cases that are 
likely to arise, this palliation can be most efficiently and properly accom- 
plished. In other words by what means can we most effectually diminish 
the amount of dropsical accumulation or prevent its increase in the various 
forms of dropsy to which I have alluded. In all those cases dependent 
upon impoverishment of the blood, there are two rational principles to 
guide our treatment. One is, to so aid nutrition by the proper regulation 
of the diet and other hygienic measures as will improve the digestion and 
assimilation of food and consequently increase the nutritive elements of 
the blood; the other, to increase the action of those organs and struct- 
ures which eliminate the watery element of the blood, and thereby 
diminish the relative proportion of that element, and increase the viscidity 
of that which remains in the vessels. You are well aware that the skin 
and kidneys are the structures through which the watery element of the 
blood is most largely eliminated. And whenever it is in excess, as it is 
relatively in all cases of impoverishment, by increasing the action of the 
skin and kidneys, and at the same time maintaining a reasonable degree 
of activity in the nutrition and formation of new materials for the blood, 
you must efficiently work in the direction of correcting the impoverish- 
ment and restoring the proper relative ratio between the watery element, 
and solid or organizable constituents of the blood, and will thereby 
directly lessen the tendency to further effusions into the tissues and cavi- 
ties of the body. But action upon the skin and kidneys in such a way as 
to largely increase the elimination of water is capable of producing effects 
beyond that to which I have just alluded. It may not only restore the 
natural rario or proportion in the different elements of the blood, and 
thereby stop the further effusion, but the watery element may be reduced, 
at least temporarily, below its natural proportion. Whenever such is the 
case, it is a physiological law that more active absorption of water takes 
place from the interstitial spaces, and such serous cavities of the body as 
may contain it, to supply the deficiency of that element in the blood. 
Consequently, whenever through diaphoresis, or diuresis the water of the 
blood is reduced below the natural proportion, active absorption takes 
place from the tissues and cavities, thereby lessening the accumulations 
and exudations wherever they may exist. And it is in this way that diu- 
retics act when they reduce the effused fluid in dropsical cases. In cases 
where the kidneys are the seat of disease, and perhaps the primary cause 
of blood impoverishment and dropsical accumulations, little can be done 
by remedies directed to increase the action of those organs. But dia- 
'phoretics, warm baths and such remedies as increase largely the flow of the 
watery element from the cutaneous surface, may be still available and 
productive of good. The mucous membrane of the alimentary canal is 



TREATMENT. 683 

also a very important milium through which elimination of the watery 
element may be increased, by giving the patient frequent doses of hydra- 
gogue cathartics, such as elaterium and the saline cathartics, sufficient 
to cause from two to four copious watery evacuations in the twenty-four 
hours, and thereby rapidly diminish the watery element of the blood. 
Practically, however, there is objection to the use of hydragogue cathartics 
very actively or during any considerable length of time, on account of 
their tendency to cause loss of appetite, impairment of digestion, and 
ultimately, positive irritation of the mucous membrane, by which more 
injury is done to the digestive organs than is compensated for by the 
increased discharge of water in the evacuations. 

In all those conditions of blood impoverishment and general dropsy 
that do not hinder the kidneys from being placed under the influence of 
diuretics, you will find it important to have some guide as to the kind of 
diuretics you should use. For instance, some cases of general dropsy are 
accompanied by small secretion of urine, and an imperfect elimination of 
the saline elements of that fluid, leaving tnem in excess in the blood and 
tissues of the body; in other words, cases in which there is imperfect 
elimination of the products of tissue disintegration. Such is usually the 
case with the general dropsies that follow attacks of eruptive fevers, or 
other general acute diseases. In these cases, where diuretics are us^d it 
is desirable to choose such as will not merely increase the excretion of the 
watery element of the blood, but will also promote especially the elimina- 
tion of the products of tissue disintegration. For this purpose the saline 
diuretics are very much more efficient and reliable than those of vegeta- 
ble origin. But in those cases of dropsy in which there is no retention of 
the elements or products of tissue disintegration, but a mere accu- 
mulation of the watery element of the blood, the vegetable diuretics 
and nitrous ether will be much more suitable for the purpose than the 
salines. The fluid extracts of galium, uva ursi, and the spirits of nitrous 
ether, aided more or less by digitalis, in many instances will be found 
more suitable in such cases and much better calculated to conserve the 
strength of the patient, and allow the continuance of efficient digestion, 
than the free use of the saline diuretics, such as the bitartrate, nitrate and 
acetate of potassium or the iodides. But in the large proportion of the 
cases of dropsy, both circumscribed, as when it exists in some one of the 
serous sacs of the body, and when it pervades the areolar tissue, your pa- 
tient will arrive at a stage where your palliative measure will become 
unavailing; neither diuretics, diaphoretics, hydragogue cathartics, nor 
any other measures that can be devised relating to the administration of 
medicine, will longer hold in abej^ance the accumulation of fluid, and some 
other measures must be adopted, or thp effect upon some one or more of 
the important functions of the body will cause a fatal termination. In 
ascites, the fullness will become such as to crowd the diaphragm up- 
wards, lessening the capacity of the chest, and by direct pressure upon 
the stomach, preventing the taking of food and its digestion to such an 
extent as to endanger the life of the patient. In hydrothorax a similar 
danger will result from a great degree of compression of the lungs. Ac- 
cumulations in the pericardium, similarly endanger fatal pressure upon 
the walls of the heart. When the dropsy is thus circumscribed, and it can 
not any longer be either diminished, or the patient protected from serious 
danger, the proper resort is, to direct evacuation of the contained fluid, 
either by paracentesis, with the trochar, or by aspiration. The latter in 
the great majority of cases is preferable for the thorax, pericardium and 



684 DROPSIES. 

• 

sometimes the membranes of the brain, while in the abdomen we may 
more freely use the ordinary trochar. 

By thus directly removing the accumulated fluid, you will temporarily 
relieve the obstructions that had previously existed, and give the patient 
at least a period of comfort, before a re-accumulation can take place. 
Such re-accumulation, however, in all cases where it depends upon an in- 
curable pathological condition, will sooner or later occur, and usually, the 
rapidity of the return will increase after each tapping or aspiration until, 
eventually, the patient reaches a stag 3 of fatal exhaustion. Yet, by the 
judicious practice of such removal life may be prolonged very much be- 
yond what it would be, if no such resort was had. In another class of 
cases affected with general, instead of circumscribed drcpsy, the patient 
may arrive at a stage where life is put directly in jeopardy by the uni- 
versal infiltration of the connective tissue of the body throughout its 
whole extent, and yet there is not such a degree of accumulation in any 
of the important serous cavities that tapping or aspiration from those 
cavities would afford the necessary, though temporary, relief. Generally 
some other mode of draining the connective tissue throughout must be re- 
sorted to, or the patient must be allowed to die. In such cases, during 
the last ten years. I have resorted, in a goodly number of instances, to a 
free incision on one side of each ankle, or a little above the internal mal- 
leolus; making the incision from an inch to an inch and a half in length, 
directly down through all the tissues to the immediate vicinity of the peri- 
osteum. By placing the limbs a little dependent, with oil cloth, or oil silk, 
to conduct the draining fluid off, so as to prevent the bed and clothes from 
becoming wet, and keep the patient comfortable in that respect, these 
incisions very seldom fail to produce complete drainage of the dropsical 
fluid, from the whole extent of the connective tissue of the body. And 
in some cases of incurable organic disease of the heart, they have relieved 
the patient almost entirely from four to six months. And when the 
incisions have healed, and the tissues have become filled up gradually, 2 
repetition of the incisions has relieved the same case, sometimes, two or 
three times, thereby not only prolonging life for a whole year, or a year 
and a half in some instances, but rendering the patient most of the time 
comparatively comfortable. The same is true in cases that result from 
renal disease; unless the incisions are postponed so long that the elimina- 
tion of urea has ceased, and ursemic poisoning has already developed in 
the nervous centers. In a few instances where the renal disease was sup- 
posed to have been permanent and incurable, complete drainage of the 
water from the tissues through the incisions in the ankles has resulted in 
the full return of the renal secretion permanently, and the consequent 
restoration of the patient. I have thus o-iven you this outline of the va- 
rieties of dropsical accumulations, or serous fluxes into the shut sacs and' 
connective tissues of the body, the different causes and pathological con- 
ditions that give rise to them, and the principles that should guide us in 
their treatment, both in reference to removal of the original disease, and 
in the palliation of such cases as admit only of this mode of treatment, 
and the prolongation of life. I will therefore next call your attention to 
the other division of fluxes which I denominate sanguineous fluxes or 
hemorrhages. 



HEMORRHAGES. 685 



LECTURE LXVI. 



Sanguineous Fluxes or Hemorrhages— Their Varieties, Causes, Consequences, and General Prin- 
ciples oi' Treatment. 

GENTLEMEN : By sanguineous fluxes, or hemorrhages, I mean the flow 
or exit of blood from the vessels in which it is naturally contained. 
The nost common causes of hemorrhage, are, solutions of continuity or 
rupture of the vessels, resulting from wounds, or injuries produced by 
mechanical violence. But all hemorrhages of this class are necessarily 
of a surgical character, and involve surgical treatment, consequently they 
are excluded from our present consideration. Leaving the hemorrhages 
that thus result from direct mechanical violence, all others may be divid- 
ed primarily into two classes : First, those which result from increased 
flow of blood to some part, or some particular vessel, faster than the cap- 
illaries are capable of allowing its transmission. Second, such as result 
from some impairment in the function or structure of the vessels them- 
selves. The first may be produced, either by severe exertion, by which 
the force and frequency of the action of the heart is increased, as in 
heavy lifting or any other violent exercise, or it may arise from simple 
increase of the muscular force of the heart in the systolic contractions, 
thereby sending the blood more forcibly, and in greater quantities to the 
parenchyma of organs and the periphery of different structures of the 
body, than is natural. In such cases, the organs which receive their 
blood in the most direct line from the heart, will feel the force of such 
increased activity in the greatest degree. Hence, most of the hemor- 
rhages that occur from these causes are from the yielding of the walls of 
vessels either in parts within the cranium, or in the Schneiderian mem- 
brane, or from the vessels of the lungs. Another less frequent, but yet 
occasional cause of increased flow of blood into certain structures faster 
than the capillaries and small vessels are capable of conveying it through, 
is an increased activity of contraction, and consequent tension of the 
coats of the larger arteries leading in any given direction, but more fre- 
quently of the aorta itself. Cases of this kind I have observed, both in 
the thoracic and abdominal sections of the aorta, and though rare, yet in a few 
instances they evidently caused hemorrhages of much the same character 
as result from hypertrophy of the heart. All the class of cases to which 
1 have now alluded, whether arising from the effects of protracted and 
severe exercise, or from muscular hypertrophy of the heart, or increased 
activity of the muscular structure of the larger blood vessels, are properly 
called active hemorrhages ; indicating by that phrase, that they result 
from increased impetus or flow of blood to the part, and not from any 
special fault in the structure of the part from which the blood flows. The 
second class of hemorrhages, however, result from an entirely different 
class of causes, having no connection with any increased flow of blood to 
the part or increased activity in the mechanism of the circulation, but re- 
sulting either from mechanical obstruction, or impairment of vessels them- 
selves. The obstructions may vary widely in their nature from each 
other. Perhaps those of most frequent occurrence are from inflammatory- 
exudations. You have noted in the descriptions 1 have given of nearly 
all the acute inflammations, when speaking of the resulting anatomical 
changes, that among those changes in the texture of organs there was to 



G86 HEMORRHAGES. 

be observed in many cases the appearance of red corpuscles of the blood 
with the exudative material, constituting minute hemorrhages from the 
inflamed and obstructed capillaries. 

These, however, are usually not included in the class of hemorrhages as 
described in your text books, but are simply spoken of as part of the an- 
atomical changes belonging to the inflammatory processes. Another 
class of obstructions in the vessels, however, that may give rise to more 
positive hemorrhages, consist of emboli or fibrinous clots and shreds, either 
formed in some portion of the vessel, or carried into it from the central 
organs of circulation. Undoubtedly many cerebral hemorrhages occur in 
this way, and some in the pulmonary structures, and occasionally into the 
parenchyma of the spleen, kidneys and liver. A still more frequent cause 
of hemorrhage from direct obstruction of the vessels of the part consists 
of tubercular deposit. This kind of deposit, as stated to you when speak- 
ing of the subject of tuberculosis, has been more frequently found in the 
lungs than any other part of the human body. The pulmonary structure 
being exceedingly vascular, and its connective tissue distensible or elas- 
tic, the deposit of tubercular matter, whether in small granules, or in larger 
masses of more friable or caseous material, is very liable to be so place i 
as to obstruct completely the flow of blood, through not only the capil- 
lary vessels, but the smaller arteries and veins. And one of the most 
common incidents in the progress of pulmonary tuberculosis of all 
varieties, is the occurrence of hemorrhage, technically called haemoptysis. 
Hence, it is often the case that these hemorrhages from the lungs take 
place early in the progress of the tubercular affection; so early, indeed, as 
to constitute the first thing to arrest the attention of the patient, and 
to impress upon him the idea that some serious disease is pending. 
Another mode of obstructing vessels sufficiently to cause hemorrhage is 
the pressure of tumors or morbid growths, or the enlargement of viscera in 
any direction, by which such enlargements are made to produce mechan- 
ical pressure sufficient to obstruct the natural passage of blood through 
the vessels. Still another class of pathological conditions which may 
give rise to hemorrhage, consist in alterations of the texture, or walis of 
the vessels of the part from which the blood flows. Chief among these 
alterations are fatty or caseous degenerations in the fibres of the muscu- 
lar coat of the vessels. Such degeneration diminishes the tonicity or 
firmness of the texture, and allows the ordinary degree of blood pressure 
to rupture the vessel walls and permit the flow of blood either upon the 
surface, or directly into the parenchyma of the texture. Familiar exam- 
ples of this kind of degeneration are found more particularly in the brain, 
in patients of sedentary habits or who have long been addicted to the 
moderate use of alcoholic drinks; by which the oxygenation anddecarbon : 
ization of the blood is retarded, thereby favoring the caseous or fatty degen- 
era ion of the structures generally. Similar degenerations take place some- 
times from age, without being preceded by objectionable habits or modes 
of life, but simply as the result of impaired nutritive changes in old age. 
A large proportion of the attacks of paralysis, especially of a hemiplegic 
character, that occur between the ages of forty and sixty years, as well as 
those of apoplex}^, are from this form of degeneration in the structure of 
the coats of the cerebral vessels. Another alteration, or pathological con- 
dition of the vessels which favors hemorrhage is defective nutrition. In 
certain conditions of the blood and of the properties of the tissues, such 
as is illustrated in the disease called scorbutis or scurvy; in pernicious 
anaemia, and other affections in which the blood is changed in its quality, 
either by impairment of its coagulability, or by so great impoverishment of 



causes. 687 

its nutritive constituents as to be incapable of affording the elements of 
healthy nutrition, or of sustaining the vital affinity governing molecular 
movements and giving tone to the tissues. Consequently the actual nu- 
trition of the vessel walls in some organs becomes so impaired, that they 
are incapable of resisting the pressure of blood in them; in such cases 
either a direct rupture of the vessel wall and hemorrhage may occur, or a 
transudation of the blood by exosmosis without visible rupture. 

Still another condition of vessels is sometimes met with, that I may 
denominate atrophy or wasting of the vessel walls with dilatation. This 
is perhaps, the condition existing, to some extent, in all cases of varicose 
distension of veins; ordinarily however, cases of this kind do not give 
rise to actual hemorrhage. But when the part is so situated, that coinci- 
dent with diminished nutrition leading to atrophy of the vessel walls, 
there is at the same time diminution of the natural amount of pressure 
from without on the vessels, as seen in advanced life in those instances 
where the brain begins to diminish in volume, leaving less pressure 
against the veins of the dura-mater, at the same time that the general 
nutrition of the veins is less than normal, we get that condition of im- 
paired vessel walls constituting a thinning with small dilatations, ruptures 
and hemorrhages of a limited amount, constituting the disease which has 
been denominated pachy-meningitis interri, and which I have already 
described to you when speaking of inflammatory affections of the mem- 
branes of the brain. Although this condition was then described in the list 
of inflammations of the cerebral membrane, it was made evident that the 
morbid conditions, and especially the hemorrhages which occur in such 
cases often leading to some of the most prominent and dangerous symp- 
toms that accompany that form of disease, arise not from inflammatory 
congestion, but from actual thinning of the walls of the vessels and the 
diminished pressure produced by the shrinking of the cerebral mass. 
Consequently the haematoma, as they are called, accompanying pachy- 
meningitis, are actual specimens of hemorrhage resulting from this 
atrophy of vessel walls and diminished pressure upon their exterior. 
Still another morbid condition of the vessels favoring the occurrence of 
hemorrhage is the impairment or suspension of vaso-motor influence, 
causing paralysis, either complete or partial, in the muscular structure 
entering into the composition of the coats of the vessels. You will 
readily see how this might favor such an accumulation of blood in the part 
as to result in the rupture of their walls and hemorrhage. The blood 
continuing to flow into the vessels by the ordinary force of the heart and 
receiving no additional impulse from contraction of the vessel walls, does 
not pass through the capillaries with the usual degree of rapidity, and 
consequently would tend directly to accumulate in the arterioles until 
over-distension might cause rupture and hemorrhage. 

The last class of causes or pathological conditions I shall enumerate re- 
late to the quality of the blood. As I remarked a few moments ago, when 
the blood is greatly impoverished in its corpuscles and albumen, render- 
ing it unnaturally thin, it exhibits a tendency to permeate the vessel 
walls, producing petechial or hemorraghic spots. When such a condition 
of the blood exists coincidently with impairment of vaso-motor influence, 
there is decided danger of hemorrhagic exudation. Still more, however, 
is this the case when impairment of vaso-motor influence in the vessel is 
associated with that disorganized morbid condition of the blood which 
exists in well marked cases of scorbutus, the plague and other malignant 
fevers, and the bites of serpents. Such cases are generally accompanied by 
hemorrhages, both from the free surfaces, such as the mucous membrane of 



G88 HEMORRHAGES. 

the month, nostrils, stomach and intestines, and into the parenchyma of 
organs, or the cutaneous or subcutaneous tissues. In the latter, it gives rise 
to the well known appearance of patechial, purpuric and hemorrhagic spots, 
which often accompany the malignant types of disease. Hemorrhages, 
when arising from any one of the last class of causes I have enumerated, 
are called passive hemorrhages, in contra-distinction to those I have enu- 
merated as active hemorrhages; the latter being the result of increased 
active flow of blood to the part, and all the former, however varied may be 
the pathological condition, having resulted from passive accumulation of 
blood in the part. 

From this review, you will perceive that hemorrhages, like the serous 
fluxes of which I have previously spoken, are all sirnplv consequences, or 
mere coincidences of preceding disease, and are therefore symptoms of no 
one morbid condition. You will also see clearly, from the number of dif- 
ferent pathological conditions that may give rise to hemorrhage, that it is 
of the utmost importance, in the management of such cases as may arise 
in ordinary practice, to so study them, that the proper diagnosis as to the 
actual causes and pathological conditions existing in any individual case 
may be duly appreciated. For, the methods of treatment must, in all 
cases, be guided largely by the preceding and accompanying pathological 
conditions on which the hemorrhage, as a mere symptom, may depend. 
As I have already intimated, hemorrhages may take place either from free 
surfaces, or into the shut sacs of the body, or into the parenchyma of dif- 
ferent organs and textures; but the symptoms which will be presented, 
will vary much in accordance with this division. When the flow takes 
place from free surfaces the symptoms resulting immediately from the 
hemorrhage will be almost exclusively such as are produced by the loss 
of blood, namely: paleness of the surface, softness and increased fre- 
quency of the pulse, diminished temperature or coldness of the extremities 
and surface of the body, great sense of weakness, with irregular sighing 
respiration, relaxation of the skin, with increased exudation or sweating, 
thirst, restlessness, vertigo, ringing in the ears, dimness of vision, and 
finally S}mcope and death from exhaustion. But when the blood, instead 
of flowing from the free surfaces makes its exit into shut sacs, or into the 
parenchyma of any of the organized structures of the body, another class 
of symptoms may be added to those I have already enumerated. 

It is true, that if the flow is into one of the larger serous sacs, as into 
the peritoneal, or pleural cavities, the quantity of blood lost in filling up 
either of these cavities may produce all the direct symptoms that I 
have indicated, even to that of death from direct syncope. But when- 
ever the hemorrhage takes place into the smaller cavities, and especially 
when it occurs in the parenchyma of organs it seldom produces its most 
disastrous effects from the quantity of blood lost, but from interruption 
of the function of the part immediately subject to the pressure of the 
accumulated blood. Even when the hemorrhage is into the cavity of the 
pleura there is perhaps more danger to life from the interference with 
the expansion of the lungs, and the carrying on of respiration, than from 
the quantity of blood lost. Still more would this be the case when the 
hemorrhage is into the pericardium. That sac would hardly contain a 
sufficient amount of blood to be fatal, merely from the quantity of the 
blood that would be withdrawn from the general circulation, but might 
readily prove fatal from the amount of pressure the accumulated blood 
would exert upon the walls of the heart. And if the hemorrhage is 
either upon the surface or in the parenchyma of the brain, where, from the 
bony encasement, there can be no distension of the walls and the pressure 



SYMPTOMS. 689 

of tbo accumulated blood must be 'brought to bear directly upon the 
cerebral substance, there is imminent danger of fatal consequences even 
from a very small amount of hemorrhage. 

Hemorrhages taking place into the cutaneous and subcutaneous areolar 
tissue, \%hile they may impede movements and interfere with the functions 
of the parts to some extent, and thereby cause the patient much inconven- 
ience, are rarely either sufficient in quantity to prove directly fatal, or to 
interfere sufficiently with any vital function to produce the same result 
indirectly. From this general review of the pathological conditions giv- 
ing rise to hemorrhages, the general lesions and symptoms which accom- 
pany them, both when from free surfaces, and the parenchyma of organs, 
you will readily perceive that it would be an unnecessary waste of time to 
take up the various hemorrhages and describe the phenomena or symptoms 
accompanying each in detail. Of those which flow from free surfaces, the 
most common are epistaxis from the Schneiderian membrane, haemopty- 
sis from the lungs, hasmatemesis from the coats of the stomach, hematuria 
from the mucous membrane of the bladder, menorrhagia from the uterus, 
and intestinal hemorrhage from any part of the mucous membrane of the 
alimentary canal below the stomach. When the hemorrhages occur into 
the connective or areolar tissue in any part of the body it takes the name 
of hasmatocele or blood tumor. 

From what I have just said in regard to the symptoms which result 
from hemorrhage, both from free surfaces and into the shut sacs and 
parenchyma of organs, it requires but a single step of inductive reasoning 
to arrive at the three leading objects to be attained in their treatment. 
These are, first, the adoption of such measures as are calculated to ar- 
rest the further flow of blood; secondly, to mitigate or remove the 
consequences of such flow as has already taken place; and third, to re- 
move as far as practicable the pathological conditions which have been 
the primary cause of the hemorrhage. If you see clearly the scope of 
these three objects in the arrest of the further flow, the mitigation or re- 
moval of the immediate consequences of that flow upon the functions that 
may be involved, and the removal of the original pathological condition 
from which the hemorrhage has arisen, you will be able, in any given 
case, to conduct its treatment on rational principles. In regard to the 
first of these objects, it will occur to you at once from what I have said, 
that the means for arresting the further flow of blood in any given case 
must depend, in part at least, upon the immediate cause of such flow. If 
the hemorrhage be one of the active class, dependent upon an increased 
impetus or flow of blood to the part, the first step in the treatment must 
be to retard that flow. Where it has arisen from some sudden or 
violent exercise, the exertion must be stopped, not only for the time be- 
ing, but permanently. If it originates from increased cardiac action, 
whether from direct hypertrophy of the muscular structure, giving it in- 
creased power to propel the blood through the arterial system, or whether 
it be from temporary excitation of the cardiac structure, the first step in 
the treatment must be to moderate the cardiac action either by direct de- 
pletion (venesection), or by cardiac sedatives and rest. The force and 
frequency with which the heart propels the blood, must be diminished. 
If the patient is plethoric, in the middle period of life, or in youth, one 
prompt venesection may be one of the most efficient means for dimin- 
ishing the cardiac force and arterial tension, thereby arresting .the 
hemorrhage. In the great majority of such cases, however, the 
prompt administration of such cardiac sedatives as directly diminish the 
44 



690 * HEMORRHAGES. 

force and frequency of the heart's action, will be sufficient for arrest- 
ing- the further flow without venesection. Among the most efficient of such 
agents are the veratrum viride, aconite, gelsemium, and perhaps I would 
be justified in putting with these the acetate of lead, particularly 
when given in as large doses as the stomach will bear. The same rule 
of treatment applies to those rare cases that appear to depend on increased 
arterial activity, especially when manifest in the coats of the aorta. 

In all cases of active hemorrhage it is not only of primary importance 
to diminish the force and frequency of the action of the heart and the 
larger arteries, and keep the patient at rest, but it is also in some of the 
cases beneficial to moderately act upon the secretions by diaphoretics, 
diuretics and mild laxatives, thereby lessening the general fullness of the 
vessels. The diet should be simple, unstimulating, and moderate in 
amount. When hemorrhage of the second or passive class occurs, in ful- 
filling the first indication I have laid down, namely, to arrest the further 
flow of blood, there is often required a very careful and accurate discrimi- 
nation between cases which may depend upon different pathological con- 
ditions of the vessels of the part. In all such as appear to be dependent 
on impairment of the vaso-motor nerve influence, inducing what might be 
termed in familiar language, relaxation of the coats of the vessels, and 
consequent retardation of the flow of blood through the capillaries, al- 
lowing it to passively accumulate without actual degeneration of struct- 
ure in the vessels themselves, there are no remedies more efficient in 
directly arresting further flow of blood than such as directly increase the 
action of the vaso-motor nerves on the contractility of the vessels. 
Ergot, or its active principle, ergotin, is one of the most efficient of this 
class of agents. The tincture of the chloride of iron, persulphate of iron, 
and most of those remedies which are recognized as astringents, produce 
somewhat analogous effects by their presence in the blood, whether it be 
by acting on the vaso-motor nerves, or directly on the walls of the vessel 
themselves. 

The first three of the agents named have been in my hands most 
efficient: namely, ergot or ergotin, the persulphate, and tincture of the 
chloride of iron. The activity with which they are administered must 
depend upon the urgency of the case, or the rapidity of the flow of blood. 
In cases of hemorrhage dependent on fatty, caseous or other forms of 
degeneration in the coats of the vessels, if not sufficient to produce im- 
mediately fatal results, will be influenced more by the use of such agents 
as improve nutrition, and at the same time increase vaso-motor influence. 
St^chnia and the mineral acids often act favorably upon this class of 
cases. They should be given in doses suited to the age of the patient 
and the condition of the digestive organs; and where there is a decided 
excess of fat, the administration of from three to five decigrammes (gr. v 
toviii) of chlorate of potash in a mucilaginous solution after each meal, 
by increasing the chlorine salts in the blood, and the consequent taking up 
of an increased amount of oxygen from the air cells of the lungs, will aid 
in oxidizing the fatty and carbonaceous materials of the blood, and 
thereby prevent further accumulation of these materials in the tissues. 
It may not aid in arresting hemorrhages in this class of patients but will 
lessen the danger of their recurrence after they have been arrested. 

The same rules and class of remedies apply to the accomplishment of 
the first object in the treatment of all the forms of hemorrhage that re- 
sult from impairment in the tone of the vessels. In those cases arising from 
toxaemic conditions of the blood, the remedies must be principally such as 
are calculated either to neutralize or remove the blood poison, in connec- 



PATHOLOGY. 691 

tion with such as increase the general tonicity of the whole vascular 
system. In other words the hemorrhage is but the symptom of the general 
disease and must be treated accordingly, that is, by controlling the patho- 
logical condition upon which it depends. I will detain you only to speak 
a few words in regard to that form of hemorrhage which takes place 
in connection with, or in consequence of what has been denominated the 
hemorrhagic diathesis or hasmaphilia. This condition is met with most 
frequently in children under the age of ten years, and occasionally at a 
later period, but very rarely in adult life. 

There are various degrees of this diathesis, or tendency to hemorrhage. 
In the great majority of cases, it is not so strongly developed as to pro- 
duce spontaneous hemorrhage from any part of the body. But when- 
ever a solution of continuity has taken place by any wound, however 
trifling or small, there is no tendency to stop the flow of the blood, but 
it oozes almost indefinitely. The extraction of a tooth in such a 
constitutional condition often incurs very dangerous loss of blood. 
The prick of a pin or slight cut of a knife in any part of the 
body causes the blood to continue oozing, with no apparent spon- 
taneous tendency to its own arrest. In some of these cases, es- 
pecially in children from two to six, eight or ten years of age, the 
tendency to hemorrhage is so strong that it will occur spontaneously 
or without' any injury whatever. I have met with some cases in which the 
flow of blood took place from the gums and mouth without any visible 
wound in the membrane lining the parts; more frequently from the 
Schneiderian membrane of the nostrils, slowly but continuously, until a 
most dangerous degree of exhaustion had occurred. I have met with 
several cases where the hemorrhage occurred in the same spontaneous 
manner, without any known provocation by wounds or bruises, into the 
subcutaneous tissue; more frequently of the lower extremities, causing 
numerous accumulations of blood and consequent tumefactions. These 
blood tumors are liable to present all those varieties of color that follow 
extravasations of blood into the tissues from ordinary bruises or contused 
wounds. In one instance two very large hemorrhages took place into the 
areolar tissue on the back between the scapulae, one of which was at least 
15 centimeters (5 inches) in diameter. The same patient had seven small 
ones in the lower extremities. It is not often that this class of patients 
have hemorrhages from the lungs, or from the stomach, unless there is a 
preceding wound or injury; but from the mucous membrane of the 
mouth, nostrils, and into the cutaneous and subcutaneous tissues, hem- 
orrhages are frequent in their occurrence and are often sufficiently copious 
to induce a very dangerous degree of exhaustion. But it is particularly 
when they accidentally meet with some slight wound, that they are liable to 
such a flow of blood as to endanger life. A few of these patients I have 
had under observation for a series of years. One in the West 
division of the city was under my care at different times as occa- 
sion might require from the age of two up to that of ten years, 
and several have been similarly under observation for two, three or 
four years. I do not now remember any case under my own supervision 
that terminated fatally as the direct result of hemorrhages. But they 
all present some evidence of blood impoverishment, such as paleness 
of the lip, a sallow or cachectic hue of the surface and sometimes a puffy 
or semi-cedematous appearance of the face and extremities. When a con- 
siderable period has elapsed without hemorrhage they are usually free 
from symptoms of disease except such as would be common to a moderate 
degree of debility or lack of power of endurance. 



692 * HEMORRHAGES. 

Pathology . — The actual pathological conditions existing in these cases 
of hemorrhagic diathesis have never been reliably and accurately deter- 
mined. Most of the older writers expressed their opinion that the 
essential defect was in the coagulability of the blood, or in its plasticitv. 

But I have seen no case in which the blood escaping from the 
vessels directly in the progress of the hemorrhage, did not coagulate, or 
in which the solidified fibrin did not possess a fair degree of tenacity. 
Chemical analysis has not resulted in the discovery of sufficient deficiency 
either in the quantity of fibrin, the amount of albumen, or any other ele- 
ments that may be supposed to be concerned in giving the blood plastic- 
ity to account for the constitutional defect. More recently, a better ap- 
preciation of the influence of vaso-motor nerves upon the blood vessels, 
and the part that the contraction of arterioles and smaller veins have in 
aiding the circulation, has led to the supposition that the defect in the 
class of cases to which I allude, was the arrest of the vaso-motor power, 
causing paralysis of the coats of the smaller vessels, thereby destroying 
their tendency to contract, and allowing passive exudation spontaneously; 
and when a vessel is severed leaving it without the power to contract 
sufficiently to close the orifice. 

Another theory or supposition is, that the defect consists in the absence 
of the usual muscular fibers naturally existing in the coats of the arterioles 
and smaller veins. The absence of these would render the vaso-motor 
influence of no effect, there being no muscular structure on which the 
nerves could act, and the vessels themselves would be without the ca- 
pacity to contract. The truth or falsity of this latter supposition ought 
to be demonstrable by dissection and microscopic study of the composi- 
tion of the coats of these smaller vessels. I am not aware that, this part 
of the investigation has been carried to the extent that it ought to be, 
and it affords a field in which some of you, who are skilled both in dis- 
sections with the scalpel, and in microscopic observation, may do well to 
enter upon the first opportunity that may be afforded you and study this 
part of the subject. My own impression is, that there is both a defect in 
the amount of muscular structure entering into the vessels, and in the 
vaso-motor nerve influence. In one case the one predominates, and in 
another case, the other. Whenever the cause depends upon a loss of in- 
nervation or defect in the vaso-motor nerve influence they are more 
amenable to treatment and more generally recover or arrive at an ultimate 
removal of the diathesis, and continue on through the ordinary period of 
life, while cases dependent on the absence of muscular fibers in the 
coats of the smaller vessels, are probably incurable. 

Treatment. — For arresting hemorrhage in these cases when called at the 
time it is in progress, whether spontaneous or from some wound or injury, 
I have found no other remedies equal in efficiency to the internal admin- 
istration of persulphate of iron and ergot, not given together, but alter- 
nately, in doses suited to the age of the patient, each once in from two to 
four hours, or from one to two hours apart, according to the gravity of 
the case, and the effect desirable to accomplish. In some of the 
cases there has been a coincident irritable and quick pulse, with slight 
febrile heat, in which the use of digitalis in connection with the ergot, has 
produced much better effects than the latter alone. A little boy, between 
three and four years of age, came under my care several years since, who 
had bled from the membrane lining the mouth and nostrils, till a dan- 
gerous degree of exhaustion had supervened. He had been subjected to 
treatment of some kind for two weeks without arresting the hemorrhage. 
On giving him a mixture composed of equal parts of tincture of digitalis 



TREATMENT. 693 

and fluid extract of ergot in doses often minims qf the mixture in plenty 
of sweetened water, every four hours, and six centigrammes (gr. i) of the 
persulphate of iron dissolved in water, between each of the doses of digi- 
talis and ergot, the hemorrhage was arrested, and then by continuing the 
same remedies at much longer intervals for two weeks, no return taking 
place, the persulphate of iron was discontinued, and the digitalis and er- 
got given every morning and evening for six weeks longer. The child in 
the meantime being kept chiefly upon bread and milk as a diet, and 
though allowed to go out, carefully avoiding excessive exercise. There 
was not only no relapse of hemorrhage during that time, but much im- 
provement in his general appearance; the effects occasioned by the copious 
loss of blood having very much diminished, the treatment was then discon- 
tinued. He remained well for six months, when, without any known 
cause, the hemorrhage again commenced. The same remedies were 
again resorted to, arresting it in two or three days, and taking pains to 
keep up a moderate amount of their use for several weeks, he remained 
exempt from further bleeding for one year. At the end of that time I 
was again summoned, and found him with a return of his old trouble. He 
again- recovered, however, under the treatment that had been previously 
adopted. I then induced his mother to continue the use of two doses a 
day of the digitalis and ergot for nearly six months, and although the 
family continued to live within my reach at least seven or eight years, I 
learned nothing of any return of the hemorrhage. In several instances I 
have known children to recover from this diathesis when it has been well 
marked and severe, so that spontaneous hemorrhage ceased to trouble 
them, but all through life there was great difficulty in arresting hemorrhage 
on occurrence of any accident that produced severance of the vessels. 
While I have succeeded better with the remedies I have indicated in di- 
rectly arresting the flow of blood, and by judicious regulation of the diet, 
hygienic measures, and the protracted use of one or two doses a day of the 
digitalis and ergot, occasionally giving for a week at a time, the tincture 
of chloride of iron in addition to the other, still there are cases in which 
other remedial agents will be required. You should always make due 
inquiry in regard to the condition of the secretions, and remedy by 
suitable laxatives any constipation of the bowels, correct derangements 
of the stomach, taking care that the urinary secretion is kept free and 
natural, and the function of the skin as well performed as possible. All 
these things require attention, yet you must remember that the leading- 
object of treatment for a considerable period of time should be to procure 
greater efficiency of the vaso-motor influence over the whole system of 
smaller vessels. Local applications other than those that are designed to 
produce temporary obstruction to the flow of blood Iry contact or pressure, 
appear to produce no beneficial result. The application of surgeon's lint 
saturated with persulphate of iron, and accompanied by a moderate degree 
of pressure, is practiced, and in some cases with benefit. When pressure 
can be brought to bear directly upon the open vessel, or vessels, it will tem- 
porarily obstruct the flow of blood. And it is possible, when the flow takes 
place from the mucous membrane of the mouth and nostrils, that the appli- 
cation of astringents, such as solutions of alum, acetate of lead, gallic 
acid, etc., may have some influence, although I have never seen instances in 
which their effects were well marked. I have seen the blood continue to 
ooze from the mucous surface of the gums and nostrils, directly in opposi- 
tion to the contact of a strong solution of persulphate of iron held in contact 
by lint saturated with the astringent material. I have seen it ooze with 
equal freedom in opposition to the constant application of powdered mat- 



C94 NEUROSES. 

ico, powdered alum and tannic acid. I have consequently been induced 
to attach little importance to local applications, other than that of simple 
pressure, where this can be brought to bear sufficient to temporarily op- 
pose the flow of blood. Passive exercise by riding in the open air, plain, 
nutritious food, and mild currents of electricity for a few minutes each 
day, wili aid in promoting the general health and nutrition, between the 
periods of hemorrhage. 



LECTURE LXVII. 



Neuroses : General Observations on the Physiology and Pathology of the Nervous Structures. 

GENTLEMEN: In the lecture on the general arrangement of dis- 
eases given near the beginning of the present course, I stated that 
the third division of local diseases would include the consideration of all 
those morbid conditions of the nervous structures of the body, not essen- 
tially inflammatory in their nature. And, to those non-inflammatory, or 
functional diseases of the nervous structures, I gave the general name of 
neuroses. The nature of the functions performed by the nervous system, 
in its several parts, is of such a character that it affords a great variety of 
phenomena, or morbid conditions, and is so connected with the mind or 
thinking faculty of man, that it has constituted a more productive, and at 
the same time a more obscure and difficult field of study than the morbid 
conditions of any other part of the human body. Hence, the special culti- 
vation of this field, during the last few years, has developed a great variety 
of divisions, or subdivisions, both of nerve functions and nervous de- 
rangements, bringing into use many additional names. Some of these 
are intended to designate morbid phenomena; others, more particularly 
to aid in making classifications founded upon the supposed pathological 
conditions, and still others, resulting from an effort to arrange them on 
the basis of etiology, and yet, without that clear and certain knowledge 
either of the subdivisions of structure, the special functions or the causa- 
tion, to enable any arrangement to be complete on either of the several 
bases to which I have alluded. Consequently, if you refer to different 
authors on diseases of the nervous system, you will find it difficult to rec- 
oncile their differences, and oftentimes difficult to prevent being confused 
by the complexity of their nomenclature. It may contribute to a clearer^ 
and more ready appreciation of the various morbid conditions of the 
nerve structures, if we keep in mind the fact that nerve matter is capable 
of being primarily divided into two forms of anatomical structure; the 
one is essentially cellular i. e. consisting of aggregations of cells or 
nerve atoms, and the other linear or arranged into fibers, and that these 
anatomical differences in the primary structure, coincide with the divis- 
ion of function into sentient, and transmitting. The word sentient 
is used to indicate or to include both the capability to receive im- 
pressions, and to originate nerve force; the other includes simply the 
power of transmitting impressions either from a sentient center to 
muscular structure, or from one center to another. The power of trans- 
mitting to muscular structures results in movements, through muscular 
contraction. 



NERVE FUNCTIONS. 095 

Those two great divisions of nerve structure have been designated as 
nerves of sensation and nerves of motion, from the days of Sir Charles 
Bell, and other early investigators in the physiology of the nervous sys- 
tem. You must remember, however, that the nerves of sensation, or more 
properly the sentient nerve structures, are again divisible into such as are 
connected either indirectly or directly with the cerebral hemispheres, and 
are consequently instruments of mind, and those which are connected 
with the various ganglia or aggregations of nerve matter, whether in the 
interior and base of the brain or in the spinal cord, or in the ganglia 
along different portions of the nervous cords that are not directly 
connected with the cerebral hemispheres in their ordinary func- 
tion. The first of these divisions, or sentient nerves, connected with the 
cerebral hemispheres, and constituting instruments of mind, are those 
which convey to the mind impressions that are denominated sensations, 
and of which the mind takes cognizance more or less. Those which are 
connected with the ganglia or aggregations of nerv^e cells elsewhere than 
the cerebrum, and not directly connected with mental perceptions, 
nevertheless receive impressions and convey or give rise to the evolution 
of nerve force in response to those impressions. The aggregations of 
nerve matter in the form of ganglia upon the roots of the spinal nerves, 
along the par vagum, in connection with some of the more important 
nervous plexuses in the thorax and abdomen, in the spinal cord, and the 
aggregations of gray matter near the base of the brain, all receive im- 
pressions, and give rise to responsive nerve force through conducting 
fibers and result in the inducement of actions, both motor and otherwise, 
as perfectly without the consciousness of the individual, as those impres- 
sions are transmitted through the cerebral nerves to the cerebral hemi- 
spheres. But in the latter case the sensation or impression produced is 
mentally perceived and recognized, in the other the sensation is received 
and responded to, unconsciously to the mind. Hence, there is, properly 
speaking, voluntary sensibility belonging to the cerebral portion of the 
nervous system, and an involuntary or organic sensibility belonging to 
the non-cerebral or ganglionic portion of the nervous system. The same 
division exists in the motor nerve structures. The one class having 
their connections and relations with the sentient nerves belonging to 
the cerebral hemispheres whose action is subject to mental consciousness, 
and the others having their connection with organic nerve centers in 
different portions of the system and performing their office in the natural 
condition independent of mental consciousness or recognition. Many of 
the neurologists and physiologists of the present day divide still further 
the involuntary or organic nervous system, making one division of it 
under various names to correspond essentially with the excito-motor 
system of Marshall Hall, which was only an extension of the respiratory 
system of Sir Charles Bell. 

In this they include all those sentient nerves and nervous centers which 
are connected with the performance of involuntary movements, in their 
natural condition independent of the will and yet within certain limits 
influenced by the will. For instance, respiration is a movement carried 
on by the involuntary nervous center in response to certain impressions 
made by the air upon the nerves of the membrane lining the respiratory 
passages and of the cutaneous surface, without any act of the will, or 
even of mental consciousness. And yet you all know that the mental 
portion of the nervous system enables us temporarily to interfere with these 
involuntary movements, so as to make them faster or slower, or to stop 
temporarily in obedience to our will. This control of the will, however, is 



GOG * NEUROSES. 

limited to a very brief period of time. To the same class belong the 
sphincter nerves of the bladder and rectum. They are capable of receiv- 
ing and transmitting impressions, and causing an active relaxation of the 
sphincter muscles and of producing evacuations without any recognition 
of the mind, or any mental action, and yet, as in the case of respiration 
wfaon the mind is awake and conscious, it is capable of regulating these 
movements within certain limits, but without absolute control. In this 
way you perceive that there is an important portion of the involuntary 
nervous system that performs its functions in obedience to excitation, and 
yet is in a limited degree under mental control. 

It was this portion of the nervous system, having its chief center in the 
medulla oblongata, that Sir Charles Bell called the respiratory, and Mar- 
shall Hall, extending it to include the sphincters of the body, denominated 
it the excito-motory nervous system. At the present time another very 
important part of the nervous system is denominated vaso-motor; by which 
is meant, that part which presides over all the muscular structures con- 
nected with the blood vessels throughout the body. Their natural office 
is to receive impressions made by the blood upon the interior of the heart 
and the vessel walls, and in response to cause such movements of muscu- 
lar fibers as will aid in moving the blood through the extended ramifica- 
tions of the vascular system with a degree of uniformity. This part of the 
nervous system is distinguished from the excito-motory, of which we have 
just spoken, by the fact that we can exert no mental control over it, even 
in the most limited manner, still, in its function it is as much excito-mo- 
tory as the other. Impressions are received, and nerve force transmitted 
in response to muscular structures commanding certain limited move- 
ments in the walls of the vessels and in the heart, without any mental 
recognition of the fact. There are also some eminent writers of the pres- 
ent day, who make still a third division of the involuntary portion of the 
nervous system, which they call the trophic nerves. To this part of the 
nervous system they attribute a certain degree of control over the molec- 
ular movements constituting nutrition and disintegration. They suppose 
the centers of this system to be chiefly in the ganglia upon the posterior 
roots of the spinal nerves, in some portions of the gray matter in the lateral 
cornua and portions of the spinal cord, and extending up into the brain 
through the medulla oblongata. 

This class of physiologists or neurologists attribute to the influence of 
morbid conditions of this trophic system of nerves, most of those changes 
which constitute atrophy of various kinds such as progressive muscular 
atrophy and the arrest of nutrition under various circumstances. It is not 
clearly established, however, that there is a valid distinction between what 
is denominated trophic nerves and the vaso-motor. If you scan closely 
the writings upon this subject, you will find a failure to maintain a clear 
line of distinction between these two. On the contrary, while writing 
upon the trophic system of nerves, apparently unconsciously the writers 
are continually representing in the group the functions which, when study- 
ing the vaso-motor, they have said belonged to that. And it is extremely 
doubtful whether there is any portion of the nervous system capable of 
influencing molecular movements through the walls of the capillaries, and 
their addition to the tissues constituting nutrition, or their detachment 
again from the tissues and return back as waste matter, — I say it is 
very doubtful whether it can be demonstrated that any portion of the 
nervous system especially influences these atomic movements, except in 
an indirect way. The vaso-motor nerves regulating the tone and caliber 
of the minute arteries and veins, are capable of influencing continually the 



NERVE FUNCTIONS. G97 

quantity of blood flowing to, or through a given part. I think all the 
phenomena that has b3en attributed to the trophic system of nerves, can 
be quite as well explained through the action of the vaso- motor system, in 
its regulating the blood supply to any given tissue, as by the supposition 
that a separate system of nerves exists which influences direct molecular 
movements. I have thus called your attention to an outline of the physiology 
and anatomy of the nervous system, that you might have clearly before 
you the essential functions of nerve matter, namely, on the one hand, 
the reception of impressions and origination of nerve foree, both 
voluntary and involuntary; and on the other, the function of transmit- 
ting impressions either from a sentient center capable of originating 
nerve force to muscular structure either voluntary or involuntary, or 
transmitting impressions from one nerve center to another. Keep- 
ing clearly in mind these functions of the nervous system, you will 
be able to study the morbid phenomena that arise from disturbance 
in any given part of the nervous system with more satisfaction than 
vou could without this definite appreciation of their natural func- 
tion. In studying the morbid conditions of the nervous system, we may 
divide them primarily into such as involve organic or structural changes, 
which is only another expression for alterations of nutrition, and such as 
are accompanied only by alterations or modifications of function without 
structural change. A large portion of the diseases included iu the first 
division pathologically, we have already considered in presenting to you 
the inflammations, acute and chronic, that affect the principal nervous 
structures of the body. It is one of the essential features of inflammation, 
as you have already le ;rned, that it involves both alterations of nutrition 
and of molecular movements, and consequently changes, at least for the 
time being, the structural condition; but passing by what we have already 
discussed under the head of inflammations, there are still changes of struct- 
ure that do not necessarily depend upon inflammatory action. These 
changes may be arranged under three divisions, namely, those that are 
accompanied by loss of substance, or diminution of atoms, generally de- 
nominated atrophy; those which are accompanied by an increase in the 
amount of structure, and consequently increased bulk, denominated 
hypertrophy; and the third, consisting neither of atrophy nor of hyper- 
trophy, but of a perversion in the molecular movements, by which the 
structure becomes changed in its composition; as when fat granules are 
deposited in the place of nerve cells, and when through perversion of the 
affinity existing in the tissue, the nerve cell is found to degenerate from its 
natural relation, as in the degeneration of nerve structure proper into the 
caseous or fatty material, or of the connective tissue surrounding nerve mat- 
ter itself undergoing similar changes. These are called metamorphoses or 
transformations of tissue, and under these three heads, atrophy, hyper- 
trophy, and transformation or degeneration of structure, we may embrace 
all those structural changes of the nervous system which are not inflam- 
matory in their character. On the other hand, we have a class of impor- 
tant and frequently recurring affections of the nerves that are purely func- 
tional, or at least are accompanied by no appreciable change of structure. 
These are appreciable to the patient only in that portion of the nervous 
system connected with the mind, simply because it is only through the 
mind that we can recognize whether the influence is greater or less, more 
or less intense. But we may apply the same rule for studying the morbid 
phenomena as shown by resulting disturbances of involuntary funct on, just 
as readily as in those connected with the mind. The only difference is, 
that the one is readily appreciable by the individual patient, and the 



698 NEUROSES. 

other is not appreciable by his consciousness. But both are capable of 
being appreciated by the physician in his study of the resulting- phe- 
nomena. The diminution of nerve sensibility, voluntary or involuntary, 
is named according to the degree of diminution, either paresis or anaes- 
thesia. The first means simply impairment of sensibility, and the latter 
loss of sensibility. Informer times it was simply denominated partial 
or complete paralysis of sensation. But the words paresis, and anaesthesia 
as applied to diminished sensibility or loss of it, you will rind now more 
universally used in the books you consult. Again, another class of cases 
is characterized by an increase in the sensibility, whether mental or or- 
ganic, above the na f ural standard, and this is generally called hyper- 
esthesia. Differing from both these, anaesthesia and hyperaesthesia, is 
perversion of the normal sensibility in the nerve structures of the body, 
in which unnatural sensations are produced, not capable of being classified 
as increased above, or diminished below, but only capable of being ex- 
pressed by the word perversion. This condition is most easily studied in 
some of the special senses; the nerve of taste for instance may be per- 
verted, so that in some instances, a sweet substance actually appears to the 
patient sour and the reverse. Perversions, to some extent, of taste are not 
infrequent. The same thing is illustrated in the auditory nerve giving 
rise to perversion of sounds, to a less degree perhaps in the optic nerve 
and its connections, giving rise to false colors. But what is thus easily 
studied because more easily appreciated in the nerves of special sense, 
exists in all the nerves of sensation, such as tactile nerves and those 
which are naturally affixed to the involuntary system; and not a few of 
those obscure chronic functional disturbances so often met with are de- 
pendent upon altered conditions of nerve sensibility in the involuntary 
nervous centers. If we extend this analytical study of the morbid condi- 
tions of the nervous system, and connect with it somewhat of the modus 
operandi of the causes capable of producing disturbance of nervous func- 
tion, we might perhaps arrive at the conclusion that all the varied morbid 
phanomena, whether of anaesthesia, hyperaesthesia or perversion of nerve 
sensibility and tra;,smissibility, were traceable to alterations in the prop- 
erties of the nerve structure. 

You will remember that in the preliminary lectures of the present course, 
I claimed that all organic matter endowed with vitality was possessed of 
two inherent or elementary properties, independent of any nervous influ- 
ence, and inherent in the living organic atom or cell, and necessary to its 
condition of life from the first aggregation of matter or bioplasm consti- 
tuting the germinal cell of the ovum up through all the stages of growth 
to the most complex of organic structures. And the necessity for acknowl- 
edging the existence of such properties is here clearly seen in the exam- 
ination of the functions, whether normal, or abnormal, of nerve matter. 
For surely there is no other structure that can communicate to nerve matter 
sensibility or impressibility, and yet agents are constantly acting and making 
impressions upon the nervous structures. There is therefore an inherent 
susceptibility, or capacity to receive impressions from external influences, 
in the primary nerve matter. And in addition to this property inherent 
in the atoms of the structure, there is the property which regulates the 
movements of the atoms constituting: the structure, such as the addition 
of new ones in the process of nutrition and the displacement of old ones 
in the waste, and this is denominated vital affinity. Now if we concede 
that the nerve structure, whether belonging to the cerebral hemispheres 
and consequently coming under the class of voluntary nerve matter, or 
purely organic or involuntary, is possessed of these two primary proper- 



GENERAL CONSIDERATIONS. 699 

ties, we can easily perceive that wherever influences are brought tc bear 
which diminish the susceptibility of the nerve structure, it would necessa- 
rily diminish its function as manifested in sensibility, or in originating 
nerve force. And if.influences are brought to bear of such nature as to 
increase or intensify the primary susceptibility in the nerve structure, it 
would result in exaltation and increase, or hyperassthesia of the sensibil- 
ity and originating force of the nerve matter; and the same would be 
true of the function of the transmitting part of the nervous system. In 
the one case impressions diminishing the susceptibility would render the 
transmission slow, while those increasing it would quicken the movements 
and we would thus have a mode by which these two morbid conditions of 
function become explainable. All those conditions accompanied by pare- 
sis or anassthesia would belong to causes that had diminished the primary, 
elementary property called susceptibility; and those which were accom- 
panied by increase or hyperesthesia would depend upon causes that had 
produced an increase of the same property. An intermediate class of 
causes, capable of making impressions and altering this property of sus- 
ceptibility, would develop those phenomena that we call perversions. It 
requires but a step further in the study of the subject to perceive 
that the same classes of causes that thus may disturb function, if contin- 
ued beyond a given length of time would almost necessarily result, on the 
one hand in corresponding diminution of molecular movements sufficient 
to result in diminished nutrition, or atrophy; on the other hand, persist- 
ence in the exaltation of susceptibility would develop an addition of new 
atoms constituting hypertrophy. While a perversion of impression would 
be precisely such as would correspond with the ultimate development of 
transformations or degenerations in the molecules of which the tissue is 
composed. These views are in strict consonance with clinical observa- 
tion. It is well known that the effects of long continued perversions of 
function of a marked character, result in change of structure from 
altered nutrition. Not only are these views susceptible of being largely 
illustrated by direct clinical observation, but a study of the causes which 
are capable of producing either alterations in the structure not of an in- 
flammatory character, or in the line of simple atrophy, hypertrophy and 
transformations, or the more temporary derangements of a purely func- 
tional character, will enable us to divide them into classes corresponding 
almost perfectly with the different pathological conditions to which I 
have alluded, namely, such causes as produce sedative impressions upon 
nerve matter and thereby diminish the manifestations of function, and if 
continued long enough, the development of structure also. Another class 
act as direct excitants, quickening function and ultimately leading to in- 
crease of structure. There is an intermediate class of cases, of a wide 
range, that can not be classed under either of these heads of simple nerve 
sedatives or nerve excitant-, but which more or less impress the nervous 
system in such a way as to alter its natural action, constituting perversions, 
or morbid impressions. And, were it not for the fact that the nerve struct- 
ures of the human body are subdivided into so many parts and exert an 
influence over so great a variety of functions, it might be possible to carry 
out a classification of nervous diseases, founded on these elementary views 
of the pathology of the nervous system. But, when you remember that 
each of these varied pathological conditions may be limited to particular 
parts of the nervous system, and that the phenomena which will be present 
within the body, will depend largely upon the particular function ovev 
which that part of the nervous system presides, you will see clearly why 
there is a seeming necessity for clinical purposes of adhering for the pres- 



700 APOPLEXY. 

ent to the older, and more common division of non-inflammatory nervous 
derangements, such as grouping them under the heads of apoplexy, epi- 
lepsy, chorea, catalepsy, convulsions, tetanus, hysteria, paralysis, neuralgia, 
insomnia, mental diseases, etc. I shall, therefore, in the further considera- 
tion of this subject, proceed to consider the particular non-inflammatory 
diseases of the nervous system under the various heads that are familiar to 
the profession at large; beginning with those conditions of the brain which 
are included under the terms cerebral hyperemia, cerebral hemorrhage 
and apoplexy 



LECTUEE LXVIII. 



Apoplexy- Its Varieties, Causes, Clinical History, Anatomical Changes, Diagnosis, Prognosis and 
Treatment. 

GENTLEMEN : The word apoplexy is used to indicate a loss of con- 
sciousness or coma, occurring suddenly without mechanical injury or 
the influence of poisons. For instance, when a patient is taken somewhat 
suddenly with feelings of vertigo, dimness of vision, a turgid condition of 
the vessels of the face, and speedily becomes unconscious with more or 
less stertorous breathing, with a slow intermittent or full and hard pulse, 
and loss of power over the voluntary muscular system, he is said to have 
an attack of apoplexy. In some cases, these symptoms may prove tem- 
porary, lasting from half an hour to one or two days, followed by slow, 
gradual improvement till they pass away entirely and the patient re- 
covers, or the improvement may proceed only to the extent of restoring 
consciousness, with ability to use one part, or one half of the voluntary 
muscular system, while the other remains paralyzed. In such cases it 
takes the name of hemiplegia or paralysis, rather than that of apoplexy. 
In still another and large class of cases, instead of the symptoms begin- 
ning after a brief period of time to improve, the unconsciousness becomes 
more profound, the pupils of the eyes dilate, the breathing becomes very 
slow and stertorous, the vessels of the face and neck very much con- 
gested, of a leaden or bluish hue, the pulse sometimes soft and inter- 
mittent, at other times small, soft ar.d quick, an entirely motionless con- 
dition of the voluntary muscular system, except perhaps an occasional 
automatic drawing up of a limb and letting it down again, relaxation of 
the sphincters, involuntary discharges and death. The latter might occur 
within even a few minutes after the commencement of the attack, or it 
might be deferred for one, two or three days. Attacks of this character 
are very rare in childhood and youth, but increase in frequency from the 
middle of adult life to old age. A very large majority of all the cases 
occur after fifty years of age. The disease does not appear to be in- 
fluenced in a marked degree by season of the year, or by climate, and but 
little by sex. In my own experience I have met with more cases in males 
than in females; and a moderately larger number during the extreme cold 
seasons of the year, than in the warm. Having used the word apoplexy 
in its generally accepted sense to cover all those cases in which there is 
sufficient interference with the circulation of blood in the central portion 
of the nervous system to at least temporarily suspend its functions, it 



CAUSES. 701 

must be admitted that pathological conditions varying much from 
each other are equally included by such use of the word, inasmuch as 
bloo I may accumulate in the nerve structure of some portion of the brain 
by simple hyperemia; or venous congestion of the minuter vessels and 
capillaries and overwhelm function, or the vessel may be ruptured from 
son;* sudden and severe pressure of blood upon its walls, or from a pre- 
vious impairment of the texture of the walls of the vessel itself, causing 
extravasation of blood sufficient by its pressure to wholly interrupt the 
further manifestation of function; or we may have emboli detached from 
fibrinous clots in the heart or some of the larger vessels and carried into 
the brain, plugging the vessels, so as to interrupt circulation and produce 
results as speedy and severe as would result from hemorrhage in the 
brain itself. Or we may have still another condition ; that of impairment 
of the vaso-motor nerve influence in the vessels of the brain, producing 
vaso-motor nerve paralysis, passive dilatation and consequent apoplectic 
pressure upon the nerve matter; thus making no less than four or five 
essentially different pathological conditions, all of which may be accom- 
panied by such interference with the circulation through the nerve struct- 
ures of the brain as to completely interrupt the manifestions of function 
or in other words to develop the ordinary symptoms of apoplexy. If we 
ma3 r thus have a variety of pathological conditions leading to the develop- 
ment of such symptoms as are called apoplectic, it follows that the causes 
of apoplexy may be equally various. 

Causes. — In directing your attention to the causes of apoplexy I shall 
divide them into those which are predisposing, and those which are more 
directly exciting causes. The predisposing causes embrace all such in- 
fluences as are capable of increasing in a marked degree the rapidity of 
the flow of blood to the brain on the one hand, and of such as, though not 
increasing the rapidity of flow to the brain, nevertheless impair the con- 
dition of vessels themselves in the brain, in such a way as to lessen their 
capacity to allow blood to pass freely through them. The other group of 
predisposing causes includes such influences as are capable of increasing 
the susceptibility or irritability of the brain substance. Among the more 
common or prominent of the first group of predisposing causes, or those 
which favor an increased rapidity of flow of blood to the head, are hyper- 
trophy of the heart with increase of its muscular walls, dilatation or en- 
largement of the aorta, carotid and vertebral arteries by which their 
capacity for carrying blood is increased, and as all the older writers 
claimed, a physical development marked by a broad chest and a short 
full neck, indicating disproportionate development of the respiratory and 
circulatory organs. You need but a moment's reflection to see that with 
a given size or capacity of the capillary vessels of the brain, and increased 
size and force of the heart, the vessels leading directly from it to the head 
would tend to carry more blood to the brain in a given period of time, and 
consequently would place the patient in a condition continually favorable for 
supplying the vessels of the brain faster than they were capable of passing 
the blood to the venous side of the circulation and consequently produce 
either capillary congestion or rupture and extravasation of blood sufficient 
to overwhelm function and produce all the phenomena of apoplexy. Any 
conformation of the system favoring thus an excessive flow of blood to the 
brain would constitute a predisposing cause of one form of apoplexy. 
Among the more common of the second group of causes, or those which 
tend to impair the capacity and activity cf the vessels of the brain render- 
ing the natural flow of blood to it liable to accumulate and produce 
apoplectic pressure, are the use of alcoholic drinks, some of the narcotics, 



702 , APOPLEXY. 

particularly tobacco, the indulgence in sedentary habits in connection with 
full diet, and in fact all those hygienic conditions which interfere slowly 
with the oxygenation and decarbonization of the bload, or tend to impair the 
activity of the vaso-motor system of nerves. The first, those which inter- 
fere with the oxygenation and decarbonization of blood slowly and 
habitually from day to day, always favor the occurrence of fatty or 
atheromatous degeneration of structure in different parts of the body. 
When such degeneration takes place in the coats of the arteries or the 
smaller vessels of the brain they not only lessen the tonicity of the vessel 
walls and favor the occurrence of rupture and hemorrhages, but they also 
lessen the efficiency of reaction or contraction of the vessels with each 
impulse of blood into them, and consequently favor passive distension or 
accumulation of blood. The presence of alcohol habitually in the blood 
as in the case of habitual drinkers is well known to do this; both in 
diminishing the amount of oxygen taken up, and of carbon exhaled from 
the lungs; and no fact is better established than that such habits con- 
tinued from year to year favor fatty degeneration throughout almost all 
the structures of the body, and frequently so in the liver, kidneys, muscu- 
lar and fibrous structures of the vascular system. Sedentary habits act in 
the same direction by diminishing the amount of exhalation of waste mat- 
ter, and the activity of the respiratory function in supplying oxygen to the 
blood. Tobacco, and other narcotic substances act more directly by im- 
pairment both of the respiratory and vaso-motor nervous systems in their 
sensibility and efficiency of action, and indirectly also favor to some ex- 
tent fatty degenerations. Another cause of predisposing character be- 
longing to this group consists in what might be termed the effects of old 
age in favoring the degeneration of structure in the vessels of the brain as 
well as an impairment of the vaso-motor nerve influence. You will thus 
see from the enumeration I have made that the group of predisposing 
causes capable of favoring apoplectic obstruction of the circulation in the 
brain are numerous and common. And your own observation and re- 
flection will enable you to add many other influences, which, when con- 
tinued from day to day through considerable periods of time would tend 
more or less actively to produce the same effects in one or the other of 
the modes I have already mentioned. 

The third group of predisposing causes includes such as are capable of 
increasing the excitability and susceptibility of the cerebral structure, as 
in the preceding lecture, you will remember, I reminded you of the ex- 
istence of inherent properties in nerve structure, as well as in all other 
living organic matter, one of which was the susceptibility to impres- 
sions. Whatever tends habitually to increase this susceptibility in 
the brain also increases the readiness with which the brain becomes 
hyperaemic or increased by fullness of blood. Perhaps there is no 
class of causes that predisposes in this direction so directly, as that 
of the habitual indulgence in violent passions and emotions of the mind, 
or in too protracted and intense intellectual application. Either of these 
indulgences, if continued for a considerable period of time, is capable of so 
increasing the excitability of the cerebral structure, as to establish an un- 
due degree of fullness of blood or hyperaemia, which would only require 
the supervention of some strong exciting cause to determine positive 
apoplectic results. You see sometimes on the one hand, in individuals 
given to over-indulgence in passions and emotions, especially those more 
or less of a vicious character, that when suddenly overtaxed by some 
violent act of exertion or some unusually strong and violent fit of anger or 
passion, they are at once and suddenly overwhelmed with an apoplectic 



SYMPTOMS. 703 

attack. On the other hand it has many times happened that those who 
have passed the middle period of life, by indulging in protracted intel- 
lectual labor through considerable periods of time and depriving themselves 
of sufficient rest every twenty-four hours to secure recuperation, have fallen 
suddenly, sometimes in the midst of an intellectual effort in the forum or 
the pulpit in a sudden and overwhelming attack of apoplexy. You will 
perceive that all the various causes that I have mentioned are more fre- 
quently brought to bear in the middle and later periods of life than at 
any other, except perhaps that of hypertrophy of the heart, and the in- 
dulgence simply of the more violent passions and emotions especially of a 
vicious character. To act as predisposing causes proper, all these in- 
fluences to which I have alluded must be continued habitually through 
considerable periods of time. Some o' them, when acting with an unusual 
degree of intensity and suddenness, may become direct exciting causes. 
As I have already intimated, sudden and violent passions in an individual 
previously predisposed, is capable of bringing on an attack, or too pro- 
tracted and intense intellectual effort when there is decided predisposi- 
tion, may produce a similar result. Any other exciting cause being 
brought to bear upon those already predisposed, such as violent physical 
exertion or extreme muscular efforts in lifting, large doses of alcoholic 
drinks or other anaesthetics and narcotics, under similar circumstances of 
predisposition, may induce so full a suspension of the vaso-motor in- 
fluence in the cerebral vessels as to determine an immediate attack. The 
presence of certain toxaamic agents in the blood are also to be considered 
as direct exciting causes, capable sometimes of producing apoplectic en- 
gorgements and death. Perhaps the most frequent of these agents are 
those derived from retained excretory elements of urine, in the progress 
of renal diseases of a structural character; as in the retention occurring 
in the advanced stages of granular or other degenerations of the kidney. 
Overloading the stomach with a full meal or with indigestible articles of 
food has sometimes by its reflex influence upon the vessels of the brain in 
persons previously predisposed, resulted in developing direct, and even 
fatal apoplectic attacks. 

Symptoms. — From the number and varying nature of the causes, both 
predisposing and exciting, which I have mentioned, you will have antici- 
pated that the symptoms which characterize attacks of apoplexy may vary 
much in different cases; and for convenience and accuracy of clinical 
history I will group all the cases into three divisions. Those belonging to 
the first group are such as are produced by causes favoring a direct in- 
creased determination of blood to the brain, and consequently may, by 
way of distinction, be called apoplexy from active determination of blood 
to the head. They are met with mostly in the middle period of life, and 
are either in persons of strongly sanguine temperament, or with positive 
structural changes in the heart giving it increased muscular force. In 
most of such persons the first symptoms of an apoplectic attack are sud- 
den and extreme congestion of biood in the vessels of the face and neck, 
giving it a very turgid and reddened appearance, sometimes with sudden 
flashes of light like streaks or flashes of fire before the eyes, sense of 
vertigo, followed quickly by dimness of vision, frequently twitching of 
the muscles of the face, jerking of the eyeballs upwards, a falling of the 
patient to the floor if in a sitting or erect position and within a very few 
moments the supervention of entire unconsciousness, in which state the 
breathing is usually slower than natural, with more or less noise occasioned 
by the rapid gathering of mucus in the fauces, imperfect control of the 
tongue, and partial paralysis of the musjular system generally. In most 



704 APOPLEXY. 

instances, though the pupils of the eyes are contracted at first, in a short 
time one or both become more or less dilated, and they are found not to 
respond to variations in light nor to maintain their natural parallelism, 
the one with the other. The face not only continues turgid with blood, 
but there is unusual redness over the whole surface of the body, neck and 
upper part of the chest, and in the severer class of cases the surface as- 
sumes more or less of a purplish redness, the extremities become cold, 
ends of the fingers leaden color and often cold, with a pulse at first firm, 
hard under the finger, full in volume, but slow and occasionally inter- 
mitting. If the case is proceeding rapidly toward a fatal result, the 
pulse every hour lessens in force, until it becomes soft, easily compressed, 
breathing very laborious and stertorous, entire motionless condition of 
the limbs, upper and lower, indicating general paralysis. The respiratory 
acts are protracted, with unusual depression of the abdominal walls with 
each expiration; sometimes at the beginning muscular twitchings, 
slight spasmodic action, and usually, as the fatal result approaches, entire 
general paralysis, involuntary discharge both of urine and faeces, and more 
and more " impairment of respiration and circulation till both cease. 
Generally, the pupils become widely dilated after the first one or two 
hours from the commencement of fatal attacks. These changes in this 
class of cases may take place so rapidly that the fattil result is reached 
within from one to three hours, or they may be more slow in their prog- 
ress, and terminate only at the end of the second, third or fourth day. 
Buu in- the larger proportion, after continuing this latter period, there is 
usually either partial or complete recovery, by a slow, steady subsidence 
of all the bad symptoms, the patient recovering gradually consciousness, 
the power of muscular action, and finally convalescence. In the second 
group of cases to which I have alluded, the symptoms usually vary some- 
what from those I have just described, more particularly in the condition 
of the pulse, and in the extent of the congestion of the face and external 
parts of the head and neck. The cases occur, not from increased impetus 
of blood to the head, but from failure in the condition of the circulation 
through the brain; and hence there is generally a supervention of the 
same vertigo, twitching perhaps of the muscles of the face, unsteady 
motion of the eye-balls, purplish color of the face, accompanied by entire 
unconsciousness, more or less labored and stertorous breathing, but with- 
out the intense congestion and redness of the face, and if congested at 
all only moderately so, and without the full labored pulse. On the con- 
trary, the pulse is soft, easily compressed, generally slower than natural, 
somewhat unsteady and not infrequently intermittent. The pupils of 
the eyes become earlier dilated, but otherwise the paralytic symptoms, re- 
laxation of the sphincters, involuntary discharges, proceed as in the cases 
already described. Or if they are less severe, accompanied by no marked 
rupture of vessels and actual extravasation of blood, there may be a slow 
recovery. The third class of cases is such as occurs in patients whose 
cerebral vessels have undergone impairment by fatty degeneration or 
otherwise, and consequently apoplectic engorgement into which they fall 
is purely of a passive character. In those of less degree of severity there 
will be but little fullness in the vessels of the face and neck, giving rather 
a purplish hue. Tne pupils of the eyes are dilated almost from the first, 
breathing unsteady and troubled at first, but not entirely stertorous, 
though less frequent than natural, but gradually passing on to a stertorous, 
irregular character in those in which the weakness of the vessels is such 
as to cause minute extravasation of blood. When such ext-.avasations oc- 
cur more freely there is sudden interruption of consciousness, with the face 



ANATOMICAL CHANGES. 705 

and lips more frequently blanched or pale; pulse extremely weak, surface 
generally cool, the ringers and toes rapidly become bluish and cold, with 
entire paralysis of the whole muscular system as indicated by absence of 
all muscular movements, immediate relaxation of the sphincters of the 
bladder and rectum, and speedy death; the patient sometimes giving 
but one or two gasps for breath. These are cases where from pre- 
vious impairment of the walls of the vessels in some portion of the 
brain, rupture takes place, and a sufficient degree of hemorrhage to 
immediately overwhelm all the functions of the brain with direct pressure. 
Occasionally a case of apoplexy may occur, as I have already mentioned, 
from emboli. Although these are much more liable to produce obstruc- 
tion in only a limited portion, of the brain, and to result in paralysis than 
in full apoplexy, yet sometimes the latter may be the result, because of 
fibrinous clots plugging up cerebral vessels, of such size as to suddenly 
deprive the brain of a large portion of its supply of blood, and there- 
fore equally suddenly deprive the patient of consciousness and cerebral 
action. Death may be almost instantaneous. Or if the vessels obstructed 
are smaller, and the circulation interrupted through more limited por- 
tions of the brain, there will consequently be less complete suspension 
of its function, which may allow the re-establishment of circulation in 
collateral vessels and a slow recovery, either partial or complete. 

Anatomical Changes. — From the description I have given both of the 
causes and of the symptoms of apoplexy in its varied forms you will 
anticipate that the pathological changes accompanying such disease will be 
varied, both in their extent and in their character. Where death has 
resulted from apoplectic engorgement of the brain in the class of cases I 
have described as resulting from active determination of blood, the brain 
may be found in either of two conditions: first, that of intense capillary 
engorgement of the smaller arteries, veins and capillaries with blood, 
making the cerebral substance redder than natural, and the cut surface 
to ooze blood from a much larger number and larger sized arteries and veins, 
than in the natural condition. Examined more closely, under proper mag- 
nifying power the venous portion of the blood will be found to have exuded 
or extravasated into the cerebral texture, with perhaps only here and 
there evidence of the extravasation of the red corpuscles and of the 
leucocytes. Such are cases in which the suspension of function has been 
complete, and fatal to the patient by the intensity of the engorgement of 
the minute vessels with only the addition of serous exudation into the 
textures. Sometimes this has been termed by different writers, serous apo- 
plexy. In other cases of this same class derived from active determina- 
tion of blood to the brain in addition to what I have described as the 
intensity of the engorgements, there will be found numerous minute 
hemorrhagic exudations, from rupture of the smaller vessels in many 
places, and constituting true but minute points of hemorrhage. In still 
other, but a smaller number of cases, the rupture of one or more larger 
vessels may take place, and a more decided hemorrhagic extravasation 
occur, giving rise to the formation of a clot imbedded in the cerebral sub- 
stance, or upon some part of the surface. In examining the brain in those 
cases which belong to the second group, or such as have been accompanied 
by impairment of the cerebral vessels, in addition to the appearance of 
accumulation of blood intensely filling the capillary vessels, together with 
either serous or sanguineous exudations or both, there will be found on 
minute examination, in many of them, all the appearances of fattv de- 
generation of the coats of the vessels, more especially in the parts of the 
45 



706 APOPLEXY. 

brain that have undergone the greatest degree of engorgement, and 
wherever ruptures have given rise to hemorrhagic extravasations. These 
degenerations will vary of course in different patients both in regard to the 
kind and extent of the structural changes. In some cases they are easily 
traced, not only in the connective tissue and muscular fibers of the vessels, 
but also in a less degree in the neurilemma of the nerve structure itself. 

Diagnosis. — There is little difficulty in making a reliable diagnosis be- 
tween apoplexy and other forms of disease of the brain. To distinguish 
it from all the varieties of inflammation of the brain and its appendages, 
you have only to compare the symptoms I have mentioned with those 
that I gave in the lectures upon the subject of inflammation of those 
structures. The suddenness of the supervention of unconsciousness with- 
out any preceding pain, fever or delirum, are so unlike the phenomena of 
inflammation, that it is hardly possible to confound the one with the 
other. The diagnosis between sudden hemiplegic attacks and apoplexy 
can not always be made at the first moment of the attack; both may be 
dependent upon the same class of causes and the same pathological con- 
ditions and in the first onset the symptoms will be identical. 

But in the hemiplegic attacks entire unconsciousness usually is of 
brief duration, and in a few hours, at most, the patient begins to show 
imperfect symptoms of returning consciousness, and perhaps at no 
part of the time has failed to continue moving one arm or one leg, while 
the other has remained motionless. But in real apoplexy, there is gener- 
ally, in addition to unconsciousness, an almost equal impairment or sus- 
pension of muscular action and motion on both sides of the body. It is 
only during the first few hours of the case, that there is difficulty in de- 
termining whether it is to be called true apoplexy, or hemiplegia. . Almost 
the only conditions which might trouble the inexperienced observer in 
diagnosis, are the profound influence of narcotics and anaesthetics. 
Some of the phenomena of profound stupor from alcoholic drinks resem- 
ble an apoplectic condition. I have seen some of these cases of profound 
stupor from intoxicating drinks in which the face had a purplish or 
leaden hue, a purple hue under the nails and ends of the fingers, a labored 
and slow breathing, a compressible, slow and variable pulse correspond- 
ing closely with many of the cases of apoplexy, dependent upon impair- 
ment in the efficiency of the circulation through the brain. But on close 
examination in all these cases, the pupil of the eye was found less 
changed than in true apoplexy. In a majority of them it is slightly dilated 
from the effects of alcohol, but not nearly so much as is usually the case 
in apoplexy, and the eyeballs almost always maintain their parallelism. 
It is very rare that there is not also a distinct alcoholic odor recognizable 
in the breath. These are circumstances which will, in a large majority of 
cases, enable you to distinguish accurately between cases of profound in- 
toxication, and that of apoplexy. Profound stupor, or narcotism from opi- 
ates, also sometimes may lead to doubt or to hesitation in comparison 
with apoplexy. There is, however, this difference in almost all instances: 
that opiates produce close contraction of the pupils of the eyes, whereas 
apoplectic attacks sufficiently profound to cause actual paralysis, and 
other conditions, compared with extreme narcotism, are accompanied by 
dilatation of the pupils, and a failure to respond to any alterations in the 
intensity of light. 



PROGNOSIS. 707 



LECTURE LXIX. 



Apoplexy Continued— Its Prognos's and Treatment 

GENTLEMEN: If what I stated in the preceding lecture in regard to 
the pathological conditions of the brain involved indifferent cases of 
apoplexy is correct, it follows, necessarily, that the disease in all its 
varieties is one of extreme danger and terminates fatally in a very large 
proportion of the cases that occur. When the disease is caused by active 
determination of blood from any cause, without previous degeneration or 
impairment of the functions of the cerebral vessels, if seen and promptly 
and judiciously treated almost immediately after the development of the 
symptoms have commenced, the disease may not infrequently be arrested. 
Indeed, with very prompt attention on the part of the physician, all the 
cases of that class, except such as are accompanied by positive rupture of 
vessels and extravasation of blood, may be relieved. Unfortunately, 
however, many of them may be so far distant from their physician, that 
the stage of intense capillary engorgement will have given place to ex- 
udation, so that practically a large proportion of this class of cases will 
terminate fatally, not so much from necessity in the nature of the attack 
as from the very brief period of time in which remedial measures can be 
used with success; this particular brief period being the one in which 
the vessels of the brain are only intensely engorged and before either 
serous or sanguineous exudation has actually occurred. Undoubtedly, in 
some cases, recovery has taken place when the treatment has been com- 
menced even after some degree of serous exudation. Relieving the full- 
ness of the vessels themselves, the serous exudation has been re-absorbed 
and removed. But as might be expected where the attack of apoplexy 
has been preceded by impairment of the texture of the cerebral vessels, 
from degeneration through long continued action of predisposing causes, 
very few are capable of surviving a full apoplectic attack. It is other- 
wise, however, with a limited class of cases in which the attack has re- 
sulted from impairment of the vaso-motor nerve influence as the primary 
pathological condition, and the apoplectic condition has come from pas- 
sive dilatation of the vessels and consequent extreme capillary engorge- 
ment. These are cases in which, if they could be properly diagnosticated 
and treatment practiced at once, efficiently, for the purpose of restoring a 
more active condition of the vaso-motor nerve influence, they might be 
arrested and a speedy recovery secured. You will perceive that there is 
necessity for a careful diagnosis, not between the apoplectic condition 
and some other disease, but between those cases of apoplexy arising from 
passive engorgement of cerebral vessels from failure of vaso-motor nerve 
influence, from those active cases in which the accumulation has taken 
place from active determination of blood to the head. 

Without such a diagnosis you would be entirely at a loss for a choice 
in the class of remedies applicable to each individual case. Nothing is 
more plain than that those remedies most efficient in relieving or arrest- 
ing the progress of an active determination of blood, causing hyperasmia 
of the brain, if applied directly to a case of passive accumulation of blood, 
under a suspension or impairment of vaso-motor nerve influence, would 
only increase the risk of a fatal result in the latter, and vice versa. It is 
therefore not only necessary, in studying the diagnosis and prognosis in 



70S APOPLEXY. 

cases of apoplexy that they be studied in relation to the general differ- 
entiation of apoplectic conditions from other diseases, but in reference to 
differences between one class of cases of apoplexy and another. This in- 
volves the necessity for a careful inquiry into the previous condition of 
each individual patient, and the circumstances and influences that have 
been actively at work with them during, perhaps, months previous to the 
attack. As a general rule, the prognosis in apoplexy must be said to be un- 
favorable, yet as I have already stated some cases are capable of recovery. 

Treatment. — As the essential phenomena of all forms of apoplexv, 
except rare cases caused by emboli, depend primarily upon pressure on 
the cerebral substance, and as this same pressure constitutes the chief 
source of danger to the life of the patient, the adoption of such measures 
as are calculated to relieve this morbid condition constitutes the leading 
object of treatment in all cases where the physician is called to the patient 
during the early stage of the disease. It matters not whether the pressure 
is the result of intense capillary congestion, serous extravasation, or hem- 
orrhagic exudation, it is the pressure in each case that suspends cerebral 
function. The second indication to be fulfilled in the management of 
cases, consists in the adoption of measures to hasten there-absorption of 
whatever exudations or extravasations have taken place, as the second 
step in the pathological changes. The third indication to be kept in view 
in the management of all such cases as do not terminate fatally, is to pro- 
mote, as far as possible, the removal of the special morbid conditions 
which may have contributed to produce an attack and which by their con- 
tinuance would directly increase the ordinary predisposition to a relapse. 
These three distinct objects to be accomplished in the management of 
apoplexy should be kept in view, and each should receive due attention; 
and the judgment and discrimination of the practitioner is to be exercised 
to the fullest extent in choosing the means best adapted for accomplishing 
those purposes in each individual case. 

In former times, before pathological anatomy had been studied with the 
care which has been bestowed upon it in later years, it was an almost uni- 
versal custom to commence treatment when called soon after the seizure 
of the patient, with the abstraction of blood, with but little regard to the 
prior history of the patient, or what might be the special pathological 
condition existing in the brain. You will readily see from the discrim- 
ination we have given of the pathological changes and symptoms, that 
this remedy, if practiced to any degree in all that class of cases which 
are characterized by degeneration of the coats of the vessels and struct- 
ural alterations in the substance of the brain, or still more in those 
where the primary step has been impairment or suspension of the influence 
of the vaso-motor nerves, it must be limited in amount, and done with 
extreme caution, only in the very first beginnings of the attack, and 
then the effects, so far as affording relief are concerned, unless followed 
promptly by remedies of a different character, would prove only tem- 
porary, and the patients would speedily relapse into a more profound 
condition of coma, than before the abstraction of blood. But in all those 
cases occurring in the early and middle part of adult life, having 
their origin in such conditions of the heart or blood vessels as give rise to 
excessive flow of blood to the brain, the prompt abstraction of blood by 
venesection is the remedy above all others best calculated to check tne 
progress of the disease by relieving the vascular fullness before any con- 
siderable exudation, either serous or hemorrhagic, has taken place, and 
consequently should be resorted to, in that particular class of cases with 
the least possible loss of time. The rule which will constitute your best 



TREATMENT. 709 

guide as to the amount of blood to be drawn is to make a free opening 
into the vein in the arm so as to allow the blood to flow in a pretty full 
stream, and suifer it to continue until the respiration and pulse become 
more steady and natural in quality, and the congested condition of the face 
subsides. Then the bandage may be removed from the arm and the flow 
of blood stopped. During the time of bleeding it is well to have the 
head and shoulders of the patient elevated somewhat on pillows, and 
when the flow of blood ceases, remove the pillows and let the patient into 
a nearly horizontal position. 

In this class of cases the bleeding should be followed as speedily as 
possible by such arterial sedatives as veratrum and aconite, in such doses 
and with such frequency of repetition as will insure an early and free sed- 
ative influence upon the circulation, with a view of perpetuating the 
eftvct that has been produced more directly by the abstraction of blood. 
While doing this, such laxatives or purgatives should be given, if the 
patient can be induced to swallow, as will produce early and free move- 
mentsof the bowels. Liberal doses of the saline cathartics, or one full 
dose of six decigrammes (gr. x.) of the mild chloride of mercury, followed in 
two hours by a saline cathartic, may be preferable to the saline without the 
mercurial. In most of this class of patients, there is increased heat of the 
head, and cold applications may be made there, while warm applications 
or sinapisms should be kept to the extremities. After the bowels have 
been freely opened, there is probably no remedy that will be more ef- 
ficient in lessening the tendency to serous exudation into the texture of 
the brain, and at the same time encourage liberal action of the kidneys, 
than moderately full doses of the iodide of potassium. The iodide of po- 
tassium and cardiac sedatives should be continued, being guided as to the 
activity of their administration by the respiration and pulse of the patient, 
till consciousness is well restored. Then, if symptoms of debility appear, 
or the action of the heart becomes quick and rather weak, digitalis may 
be given in connection with the iodide of potassium, instead of continuing 
veratrum or aconite. If after consciousness has been restored, the patient 
exhibits a considerable degree of restlessness, and indisposition to sleep, 
the bromides and belladonna will be mare likely to induce a fair degree 
of rest, and with less risk of doing harm, than any preparation of the 
opiate class. In some cases in which a prompt free bleeding has been 
attended at the beginning with partial relief of the cerebral pressure, in 
from twelve to twenty-four hours the patient ceases to improve, and 
exhibits an increase of the symptoms of congestion and pressure, the ap- 
plication of leeches to the temples and mastoid spaces, sufficient to pro- 
duce pretty free local bleeding, will frequently be of much advantage, and 
be safer perhaps than a repetition of the bleeding from the arm. While 
treatment by direct and active depletion, arterial sedatives and active 
evacuants, such as cause free movements of the bowels and secretion from 
the kidneys and skin, constitute plainly and unmistakably the appropriate 
treatment for the class of cases of apoplexy dependent on active deter- 
mination of blood to the head, even where there may be more or less exuda- 
tion, either serous or hemorrhagic; in all those cases in which the dis- 
ease has supervened, not from active determination of blood, but from 
some cause which has impaired the action of the vessels in the brain, the 
question of the direct abstraction of blood either by venesection or leeches 
is one of no small difficulty to decide, especially in some of the cases. 
For instance, in such as have been induced by excessive and protracted 
mental exercise, or that class of causes which I have described as calcu- 
lated to increase cerebral excitability, together with all those cases that 



710 APOPLEXY. 

may have originated with paralysis, or impairment of the action of the 
vaso-motor nerves of the brain, if the patient is brought under observa- 
tion very speedily after the commencement of the attack, the abstraction 
of blood, either by venesection, or locally by leeches, to a moderate ex- 
tent, will usually be found advantageous. But the bleeding in such cases 
can not be carried to the same extent as in those that have been caused by 
active determination of blood. 

It will seldom be admissible in these cases to take more than from ten 
to fifteen ounces of blood by venesection, or to apply at one time more 
than from six to eight good leeches. The whole object of the bleeding in 
these cases is to give a temporary moderate degree of relief to the vascu- 
lar fullness, for the purpose of gaining time to obtain the action of such 
agents as may be necessary to re-establish, on the one hand, vaso-motor 
activity, and on the other hand to directly retard the morbid excitability 
of the cerebral structures. But experience has demonstrated that when 
there is present sufficient positive accumulation of blood to overwhelm 
the cerebral functions, and produce ordinary symptoms of apoplexy, even 
in this class of cases, the abstraction of a few ounces of blood sufficient to 
diminish that fullness, will enable the other remedies, especially those 
calculated to increase the activity of the vaso-motors in restoring the tone 
of the vessels, to act much more efficiently than they would without 
the temporary relief afforded by the loss of blood. In all these cases, 
you perceive, it would be a very great mistake to bleed to the same 
extent as in the first, and a greater mistake still to follow bleeding by 
the same arterial sedatives. For here, the heart's action is usually dimin- 
ished in force, the tone of the vessels themselves impaired, and we would 
consequently follow the moderate check to the fullness, with such means as 
will most speedily and efficiently increase the tone of the vascular system 
through the vaso-motors and diminish the excitability of ihe cerebral 
structure. For these purposes, efficient doses of ergotine, addressed to 
the vaso-motor nervous system is perhaps the best that can be resorted to, 
and if the action of the heart be actually irregular, giving alternately 
with the doses of ergotine, moderate doses of digitalis, or its active prin- 
ciple, digitaline, will sometimes be found of more or less advantage. In 
those cases which are associated with increased cerebral excitability pre- 
ceding the attack, instead of the ergotine, bromides may be conjoined 
with digitalis, or the combination of bromides and iodides in moderately 
full doses given alternately with the digitalis, will effect the double pur- 
pose of securing the sedative effect of the bromides upon the nerve ex- 
citability, sustaining cardiac or vascular tone by the digitalis, and the 
counter-action to some extent at least of serous exudation, by the in- 
fluence of the iodides. While these remedies may be administered as 
speedily as they can be brought to bear in the early progress of the case, 
it is desirable to procure also early evacuations from the bowels; not as 
freely and thoroughly as in cases of active determination of blood, because 
it is not desirable to largely deplete in any way this class of subjects. 
But a moderately free movement of the bowels, warm and stimulating 
applications to the extremities, as by bottles of hot water or mustard 
sinapisms, with cold applications to the head, would be desirable. The 
cases most difficult to devise remedies for are such as are dependent 
directly upon fatty degeneration of the cerebral vessels and more or less 
of the cerebral substance, and sometimes connected with more or less 
calcareous deposit in the vessel walls, as is the case in a iarge proportion 
of apoplexies that take place in advanced life. Nearly all such cases are 
accompanied from the outset with either rupture of some portion of the 



TREATMENT. 711 

degenerated vessels, and sufficient extravasation of blood to form clots 
and very speedy fatal compression, or numerous smaller ruptures, causing 
hemorrhagic exudations, and it is exceedingly difficult to devise any 
remedial agents which are calculated to afford even the most temporary 
relief, or to make any impression upon the progress of the case. Con- 
sequently, nearly all such cases terminate fatally without exhibiting any 
marked changes from whatever treatment may have been adopted. 

In some cases of merely threatened apoplexy, the symptoms, indicating a 
strong tendency to develop only partial attacks, may sometimes be warded 
■ iff by the administration of nerve tonics, ven- moderate evacuations, the 
promotion of secretion, entire quiet to the patient, and the use of mild 
nourishment. But such warding off usually proves only temporary, and 
sooner or later is followed by a full and fatal attack. The treatment I 
have now suggested as applicable to the different forms of apoplexy, is 
as well calculated as any I have been able to devise to fulfill the first and 
second indications that I pointed out, namely, relief of the vascular full- 
ness and the promotion of the re absorption of whatever exudation, 
whether serous or hemorrhagic, may have taken place. In those cases in 
which cerebral hemorrhage occurs, and it does not prove directly fatal, 
there is almost always only a partial recovery. After the treatment I 
have mentioned, the immediate pressure is relieved, consciousness returns, 
but the patient remains paralyzed in some part of the system, more fre- 
quently one side, constituting hemiplegia from the continued pressure of 
the clot that had formed from the extra vasated blood: it is exceedingly 
slow in disintegrating, and seldom fully disappears. In such cases, after 
the active symptoms have passed by and the patient has made the partial 
recovery to which I have just alluded, perhaps the management which 
will be most likely to effect further disintegration and absorption of the 
hemorrhagic clot, and preserve the cerebral substance with which it is in 
contact from undergoing degenerative changes, will be the use of a mild, 
simple diet, consisting mostly of milk, farinaceous articles, with but little 
meat, yet sufficient in quantity to afford a fair degree of general nutrition; 
careful abstinence from any undue physical or mental exercise, and the use, 
for a considerable period of time, of moderate doses of the iodide of potas- 
sium alone, or if there be undue cardiac irritability indicated by a quick, 
irritable and rather compressible pulse, digitalis will make a valuable ad- 
dition to the iodide. 

If the patient is restless, especially, not inclined to get a fair degree of 
sleep at night, this may be best obviated in most cases, by giving a single, 
moderately full dose of the bromide of ammonium or of potassium near 
bedtime. Sometimes it will add to the efficacy of this, if it is given 
in connection with as large a dose of hyoscyamus or belladonna, as will 
be borne without drying the mouth and fauces or altering the pupil of the 
eye. It is desirable as far as possible to avoid opiates, not only because 
they tend to increase the fullness of the cerebral vessels, but they also 
tend to impair the patient's appetite and constipate the bowels, as well 
9S to lessen secretory action generally. In most of the cases now under 
consideration, the bowels are almost always habitually inclined to consti- 
pation. It is necessary to devise means to obviate this and maintain as 
healthy a regularity as possible; for by so doing, you will do much to 
guard against a renewal of the cerebral attacks. In many of this class, 
the bowels can be best regulated by giving a pill every evening, com- 
posed of six centigrammes (gr. i) each, of the extract of hyoscyamus, 
sulphate of iron, aloes and blue mass, with two centigrammes (gr. %) of 
the extract of nux vomica added to each pill. In a majority of patients, 



712 APOPLEXY. 

one pill containing these ingredients given regularly at night, will estab- 
lish a natural, healthy evacuation the following day. Where the subjects 
are advanced in life, and affected by more or less of the degenerative 
changes, all depressing agents, such as iodide of potassium alterants of 
any kind or evacuants, except such as are calculated to keep the digestive or- 
gans in good order, are to be avoided. A mild, unstimulating but nutri- 
tious diet as far as practicable, good air, passive exercise by riding, and 
sometimes mild tonics will be required to give this class of patients the 
most comfort, and the longest duration of life. In the treatment of the 
convalescing stage of all cases of apoplexy, it is necessary to take great 
care for several days, and sometimes-weeks, to avoid every kind of mental 
and physical excitement or exertion. Quiet is of great value. I know of 
no class of patients predisposed to apoplexy, or recovering from a direct 
attack in which any form of diffusible stimulants are of value. A very 
moderate use of tea and coffee may be allowed more especially to the 
aged; where there is no direct increased cardiac force or irrita- 
bility, tea and coffee used moderately, will seldom produce unpleas- 
ant effects. But the alcoholic class of agents, whether fermented or 
distilled, are directly and positively objectionable, both on account of 
their tendency to produce deficient oxygenation and decarbonization of 
the blood and favor fatty degenerations, and also on account of their di- 
rect anaesthetic effect upon the sensibility of the cerebral substance, and 
upon vaso-motor nerve influence. 

I have met with a few patients a little past the middle period of life, 
two of whom live still under my observation, who have repeatedly mani- 
fested symptoms indicating imminent danger of full apoplectic attacks. 
One of these is a female, about forty-five years of age, who during the last 
six years has been habitually inclined to deficient urinary secretion, but 
without evidence of any structural disease of the kidneys, also a moderate 
increase of flesh or fullness, and some degree of constipation, but no car- 
diac hypertrophy, and no undue fullness or tension of the pulse. Almost 
regularly during every year she has exhibited an increase of cerebral full- 
ness or congestion in the vessels of the brain, until, if not interfered with, 
she would be seized with vertigo, dimness of vision, slight twitching of the 
muscles of the face, and a complete suffusion, or congestion of the vessels 
of the face, neck and head, causing the surface to have an almost purple 
color accompanied by every symptom of immediately impending apoplexy. 
When these attacks first made their appearance I resorted to every means 
that I could devise for warding off the threatened apoplectic condition, 
without resorting to direct abstraction of blood. Free opening of the 
bowels, diuretics, cold applications to the head, sinapisms to the extremi- 
ties, and at first vascular sedatives were used. Failing to get benefit from 
these, vaso-motor excitants and full doses of ergotine were tried but all 
without any perceptible relief. A vein was then opened in the arm and 
blood drawn, to the extent, in the earlier attacks, of from half to two 
thirds of a liter (|xvi to |xx). This was followed by relief both speed} T 
and entirely satisfactory. And subsequently the palliating remedies ad- 
dressed to an increase of the secretion of the kidneys, regulation of the 
bowels, and of all the functions that might be out of order, produced 
effects very much more ready and satisfactory than the same remedies 
before the abstraction of blood. I have apparently warded off these at- 
tacks in both the patients alluded to, for the last six or seven years, by 
the occasional abstraction of blood. During the later years not more 
than 260 or 360 cubic centimeters (Jviii or ^xii) have been required to afford 
the needed relief. During the last five years one of these patients has 



TREATMENT. 713 

been under the care, at different times, of several other physicians, who 
most perseveringly endeavored to afford relief without resort to bleeding, 
but with no better success than I had myself. I have no doubt but that 
the patient would have died several years since, instead of being in such 
health as to be able to superintend her household affairs, as she is at 
present, if venesection had not been resorted to for her relief. 

Another equally well marked instance is an adult male engaged in 
mercantile business, in which the threatened cerebral congestion was asso- 
ciated with very marked increased action of the heart, with no apprecia- 
ble indication of valvular disease or structural changes, but an increased 
activity, apparently extending to the aorta and the vessels of the neck. 
This case, when first coming under my observation presented such symptoms 
as indicated, a turgid condition of the vessels of the face and a nearly 
suspended cerebral function, and caused no hesitation in resorting to ve- 
nesection. The patient was bled to the extent of nearly one liter (|xxx). 
He too had been subject for a considerable time to defective action of 
the kidneys, slight tendency to constipation, and had noticed some degree 
of vertigo. He was a man of naturally sanguine temperament, broad 
chest, short neck, and in his case after the prompt relief that was ob- 
tained by the free bleeding, he was put directly upon the use of 
a combination of bromide of lithium, wine of colchicum root and 
for a time the tincture of veratrum viride, and with the most de- 
cided beneficial effect. The urinary secretion became abundant, the 
excitability of the heart and cerebral vessels apparently returned to the 
natural standard, and by the continuance of full doses of this combina- 
tion of remedies each night and morning for two or three months, the 
patient gained an exemption from this tendency to cerebral congestion, 
which had lasted him through at least two full years. Subsequently, 
when indulging more sedentary habits than usual, the symptoms returned 
upon him, and with such a degree of intensity as required another, but 
more moderate bleeding. Since that time, now four years, the re- 
sort for a few weeks at the time, two or three times a year, to the use of 
a combination of bromide of lithium, wine of colchicum, and tincture of 
digitalis, in moderate doses, at first three times a day for one week, and 
then morning and evening for a few weeks subsequently, has kept him 
from any return of symptoms sufficient to attract attention, or interfere 
with his u^ual occupation. I have mentioned these c;<ses, and the treat- 
ment that I have given them, for the purpose of guiding you in reference 
to similar cases that are liable to be met with in practice, especially among 
patients of sedentary habits, accustomed to moderately full living, and who 
at the same time have much of either business or other cares and mental 
anxieties influencing them. Of course, in the management of all such 
patients, strict attention should be given to the judicious regulation of 
their diet and their exercise; to the condition of the digestive organs, as 
well as some degree of attention to the condition of the renal secretion. 
The latter escapes attention very frequently, when it would be very much 
to the advantage of the patient if it was as studiously inquired after and 
properly regulated, as the evacuations from the bowels, or the condition 
of the digestive organs, which are not nearly as likely to produce direct 
effects upon the brain as deficiency in the quality and quantity of the urine. 



14 PARALYSIS. 



LECTURE LXX. 



Paralysis— Its Varieties, Causes, Clinical History, Anatomical Changes, Diagnosis, Prognosis and 
Treatment. 

(1 ENTLEMEN: After directing your attention as much in detail as is 
X necessary to the nature and management of the different varieties of 
apoplexy. I next ask your attention to a subject in some respects closely 
allied to it, namely paralysis. This term is made to include a group of 
affections differing in many respects, especially in regard to their patho- 
logical relations, causes, symptoms and consequences. The word implies, 
as it is generally used, impairment or loss of the natural function of nerve 
structure. And as the functions of the nervous system are two-fold, 
sensory and motor, paralysis may consist in impairment or complete loss, 
either of the function, pf sensation properly denominated ana3s- 
thesia, or of motion by which the muscles supplied with the nerves 
whose motor power has been lost, become inactive or incapable 
of normal contractions. Sensory and motor paralysis may exist to- 
gether, causing a loss both of feeling or sensibility and the power 
of motion, or either one may exist separately without the other. 
Oases of paralysis are often named in reference to the immediate or 
proximate cause: cerebral, when the cause or pathological condition 
giving rise to them is located in any part of the brain or contents of the 
cranium- spinal paralysis, when the seat of the disease is in some portion 
of the spinal cord; and reflex paralysis when the primary seat of irritation is 
in the periphery of some one or more nerves, and the influence is re- 
flected upon the nerve center either in the cord or brain. Some writers 
group their cases of paralysis not in accordance with their direct proxi- 
mate cause, their location or the pathological condition giving rise to 
them, but in accordance with the extent and location of the parts 
paralyzed; as facial paralysis, when the parts affected are only some por- 
tion of the face; or if it affects a particular muscle only, the name will be 
indicated by the name of the muscle involved. If it affects the whole of 
one side, they denominate it hemiplegia. If it affects a part of both lower 
extremities, or the whole up to a given line transversely, it is designated 
paraplegia. In considering the non-inflammatory conditions capable of 
giving rise to paralysis, either motor or sensory, we find almost the same 
pathological conditions, either in the brain, medulla or spinal cord, that I 
have already described as giving rise to apoplexy. The chief difference is 
generally in the extent of the parts involved. In apoplexy, the congestion 
of the cerebral mass is more general, or if it depends upon hemorrhagic ex- 
udation or extravasation, the quantity of blood extravasated is sufficient 
not to interrupt merely the function of a portion of the brain, but of the 
whole. And if degeneration of vessels and cerebral structure from any 
cause, whether from age, from the action of alcohol, syphilis, or any other 
toxaemic agent acting through the blood, affects but a limited portion of 
the cerebro-spinal substance, instead of producing apoplectic symptoms, 
it will only cause suspension of the functions of the parts, sensory or 
motor, to which the nerves are distributed, having direct or indirect con- 
nection with the locality in which the disease exists, and consequently 



HEMIPLEGIA. 715 

will constitute paralysis instead of apoplexy. But when this condition 
exists in the cerebral substance, it frequently happens, as I have men- 
tioned when speaking of the symptoms of apoplexy, that the attacks 
primarily present all the symptoms of the latter disease, but in the prog- 
ress of recovery the greater portion of the cerebral mass becomes relieved 
from pressure, apoplectic symptoms disappear, but paralysis, usually in 
the form of hemiplegia, is left. In such patients you can maintain no 
line of distinction in the primary seat of disease, between apoplectic 
and paralytic attacks. They are identical; the paralytic condition 
being the result of only a partial recovery from cases presenting all the 
characteristics of apoplexy at their beginning. In the further considera- 
tion of the subject of paralysis, I shall direct your attention, first, to those 
cases which, the pathological lesion being in some part of the cerebral 
mass, may properly be called cerebral paralysis; second, to those originat- 
ing from changes in some portion of the spinal cord, under the name of 
spinal paralysis, including what is denominated as infantile paralysis, 
reflex or indirect paralysis, and what might be termed hysterical or ialse 
paralysis. 

•Hemiplegia. — As the word would indicate, hemiplegia means paralysis 
more or less complete of one half of the body, including one upper and 
one lower extremity, and is the most common form of paralysis resulting 
from non-inflammatory affections within the cranium. Attacks of hemi- 
plegia ordinarily commence suddenly, often without premonitory symp- 
toms of more than a few minutes' duration. In some instances, however, 
there are sensations of numbness in the hands and feet, or both, occurring 
at short intervals, and in others vertigo, for a considerable period of time 
before a decided attack of paralysis supervenes. In a large majority of 
instances, however, complete hemiplegia arises from either emboli ob- 
structing suddenly one or more cerebral vessels, or the rupture of some 
vessel, the walls of which had become more or less weakened by degener- 
ation, and the extravasation of blood. A considerable number of cases 
met with in practice are simply the sequelae of attacks of apoplexy, during 
which hemorrhage had taken place causing the formation of a clot, which 
remains after the more fluid part of the blood has been absorbed. The 
presence of such clot is sufficient to prevent the resumption of the com- 
plete functions of the motor influence emanating from the hemisphere 
into which the hemorrhage had taken place, 'and consequently hemiplegia 
remains. In all the classes of cases that are dependent either upon embol- 
ism, or upon the extravasation of blood, the primary symptoms supervene 
suddenly. The symptoms which more particularly characterize hemip'e- 
gia when it is complete, embracing one side of the face, neck, arm, leg 
and one half of the tongue, are the drooping or relaxation of the muscles 
of the paralyzed side of the face, which cause the mouth to be drawn to 
the opposite side whenever the muscles contract, giving to the face an 
expression of laughter. There is difficulty of moving the food in the mouth 
from the paralyzed condition of the buccinator muscles, and the turning 
of the tongue toward the paralyzed side when it is protruded, because of 
the action of the muscles upon one side only. There is also impaired 
deglutition and speech. The paralysis seldom includes the nerves supply- 
ing the eyelids, or the muscles controlling the eye-ball, consequently move- 
ments of these parts remain on the paralyzed side the same as on the other. 
The arm, however, hangs motionless, and when the patient is raised into 
the erect position, the shoulder droops, and the lower extremity fails of ail 
power of motion. Sensibility in most instances remains nearly perfect 
throughout, but in some there is impairment or loss of sensibility as well as of 



716 HEMIPLEGIA. 

motion. In some cases the paralysis embraces the viscera of the pelvis, 
so as to paralyze one half of the rectum and bladder, giving rise either to 
retention of urine till the bladder is overfull, when it would dribble, and 
the discharge of faeces with only a very partial control on the part of the 
patient. When complete hemiplegia has supervened, presenting the 
symptoms just described suddenly, it renders the patients usually for the 
first week entirely helpless; and they may remain so, failing in strength, 
without control over the sphincters of the body, and the temperature of 
the extremities falling below the natural standard. The dribbling of 
urine and wetting of the bed, unless great care is taken to avoid it, 
hastens the appearance of inflammation, excoriation, and sometimes gan- 
grene over the hips and nates or parts in contact with the bed, leading, 
in many instances, to deep and large bed sores; the patient loses his ap- 
petite, the mind becomes weakened, sometimes wandering, and after 
lingering in a very uncomfortable condition of entire helplessness from 
one to six weeks, death may supervene, apparently from asthenia or 
exhaustion. 

But in a very large proportion of cases of hemiplegia, whether orignat- 
ing from full apoplectic attacks or from hemorrhagic exudation, the pa- 
tients, instead of failing, as I have just mentioned, slowly improve fr m 
day to day, more especially in the movement of the muscles of the face 
or tongue, so much so that in many the face becomes nearly even, onlv 
active muscular action showing impairment, and the movement of the tongue 
being entirely restored. These improvements also enable the patient to 
regain his usual freedom of speech and deglutition. While these improve- 
ments are taking place in the paralyzed parts of the face, tongue and neck, 
there is usually a manifest improvement perceptible in the ability to 
move the arm an 1 the leg. At first, this consists simply of the power to 
slightly draw the leg up an inch or two, by bending the knee, and of 
making a motion of the arm more from the muscles of the shoulder, than 
from those on the arm proper. It is seldom that such patients suffer 
from any severe pain in the head, or any other part of the body, unless 
it is from being compelled to lie or sit too long in one position. Those 
that present these improvements usually recover also pretty fully the con- 
trol of the bladder and rectum. They have a good appetite, and in all re- 
spects feel well, except the inability to use the upper and lower extremity. 
Where the improvement takes place thus far, the patient usually com- 
mences to get upon his feet, and to make efforts to walk. These efforts 
to use the paralyzed limb become systematic, and with the aid of a cane 
or a crutch, they are able to walk, by giving to the paralyzed leg a swing- 
ing or partially circular motion, bringing it forward more by the swinging of 
the pelvis forward, than from the regular picking up of the limb and set- 
ting it forward, as is natural in the process of walking. This mode of walk- 
ing is peculiar to the partially paralyzed of a hemiplegic character. In al- 
most all cases, where partial recovery takes place, the patient being able 
to be upon his feet, the recovery of the use of the leg is much greater in 
proportion than that of the arm and hand. As the patient feels less 
necessity for the daily efforts to use the paralyzed hand and arm, the 
other affording a ready substitute for most of his wants, they are allowed to 
remain more passive, and consequently are much s'ower in recovering, and 
generally recover "less perfectly than does the lower extremity. If the 
paralysis has originated primarily from serous exudation, or oniy a partial 
plugging of the vessels by an embolus, recovery may be complete, and 
that in the course of fro:3 three to six weeks, by the re-absorption of 



SYMPTOMS. 717 

the exudative material, and the dissolution or disappearance of the em- 
bolus that had obstructed the vessels and temporarily suspended circula- 
tion in a portion of the cerebral substance. It is not always, however, 
that emboli are capable of removal in this way, consequently many cases 
dependent upon them, either make only a partial recovery or no improve- 
ment. 

Those cases of hemiplegia that occur from direct extravasation of blood 
and the formation of fibrinous clots, very rarely progress to an entire re- 
covery, but only make such a degree of improvement as enables the patient 
to walk with some difficulty and unsteadiness by bringing the leg forward 
at each step with a semi-rotatory motion of the pelvis, Avhile the hand and 
arm remain almost entirely useless. When the disease becomes thus per- 
manent it may remain stationary for a very variable period of time. 
Cases that have come under my own observation have remained appar- 
ently stationary for several years. But in all of these, sooner or later, there 
have been renewals of the extravasation or exudation of blood, bringing 
renewals of a more complete hemiplegia, until in some instances the 
extravasation has been sufficient to overwhelm the functions of the brain, 
inducing coma, universal piralysis and death. In other cases there has 
been no relapse in their progress, but the brain surrounding the clot has 
undergone a slow degenerative process, usually of the nature of an arrest 
of nutrition, and consequently softening of structure, correspondingly 
impairing more and more the strength of the patient and his ability 
to use either the upper or lower extremity. At the same time I have 
noticed a decided failure in the mental capacity, usually in the direc- 
tion of simple mental weakness, impairment of memory, incoherence 
and steady progress toward imbecility. This slow deteriorative proc- 
ess in the cerebral substance surrounding the primary clot may increase 
gradually till at the end of two, three or four years the patient becomes 
quite imbecile, paying little or no heed to evacuations of urine or fasces, 
yet taking food freely and even ravenously whenever it is put into the 
mouth, but manifesting neither capacity for connected thought nor mental 
activity, and becoming entirely devoid of ability to maintain the upright 
position, either upon the feet or in the sitting posture. In this condition 
of helplessness and mental imbecility he may still live for a considerable 
period of time; but usually sinks gradually into an unconscious condition 
with general paralysis and dies. Such is a general statement of the symp- 
toms and progress of the common forms of hemiplegia, resulting from 
non-inflammatory obstructions in some portion of the brain. Cases may 
be met with in which the lesion is in the brain, and yet it may not im- 
pair or paralyze the entire half of the body, but only a certain portion of 
one side; as when it interrupts the function only of the motor nerves of 
one side of the face, producing what is thus styled facial paralysis. In 
another instance it affects only the function of those nerves which supply 
the arm, rendering it incapable of motion, while the face above and the. 
lower extremities remain unaffected. In perhaps a smaller number of 
cases, a single leg may be paralyzed without involving the arm or the 
face and yet the seat of disease may be in the brain. Ferrier, in his 
efforts to localize the functions of the brain, has pointed out particular 
parts, which, when obstructed by hemorrhagic exudation, tumors or any 
other mode of pressure, had given rise to movements in particular parts of 
the body. He claimed to have established the fact that when one leg 
was paralyzed the seat of disease was in that part of the cerebral mass 
above the corpus-callosum of the side opposite to the leg paralyzed. In 
paralysis of the uppar extremity, the seat of disease was somewhat 



718 HEMIPLEGIA. 

anterior, and connected with the anterior lobe of the brain, or near its 
junction with the middle lobe. While in paralysis of the face, muscles of 
the tongue, and especially in aphasia or that form of paralysis destroying 
the ability to speak, the seat of disease was said to be located in the con- 
volutions on the inner side of the anterior lobe, opposite to the parts 
paralyzed. These views of Ferrier have many facts to confirm them, and 
yet they require a much larger collection of pathological facts and results 
of recorded cases to establish their absolute correctness. 

Anatomical Changes. — When death takes place from hemiplegia, and a 
post-mortem examination is had, the anatomical changes found in the brain, 
differ in different cases, and with differences in the length of time that the 
disease had existed before the death. In those cases that supervene sudden- 
ly producing complete hemiplegia proceeding to a fatal result early, there 
will usually be found simply a rupture of one or more blood vessels, and 
the extravasation of blood, the serous portion of which may have been 
partially absorbed, but a fibrinous clot isleft. In most instances, close 
examination will show that the extravasation has been the result of 
fatty degeneration of the coats of the ruptured vessels, or some other 
form of structural impairment. It is very rarely that such rupture has 
taken place, unless from direct violence, without proceeding from condi- 
tions impairing the structure of the vessels themselves. In some instances, 
examination has shown the origin of the disease to have been in the 
plugging of one or more vessels by emboli, or fibrinous clots. In such 
cases the portion of the brain supplied by the vessels thus plugged will 
exhibit deficiency in the supply of blood, provided the vessel is an artery. 
If it be a vein, the capillaries and smaller arteries connected with the 
distribution of the vein may be intensely engorged, or even exhibit serous 
or sanguineous exudation into its texture. In some instances, the par- 
alysis or hemiplegia has been found dependent on the formation of one 
or more tumors, which had developed either in the cerebral substance or 
in the membrane covering it. Tiie most common form of morbid growth 
is sarcomatous enlargement of the glands lying along the longitudinal 
sinus, or in the vicinity of it, more frequently than elsewhere. Some- 
times tumors originating in the membranes of the brain attain consid- 
erable size, developing slowly, and the cranium being incapable of yield- 
ing, the tumor becomes imbedded deeper and deeper into the cerebral 
substance, producing a variety of symptoms during its progress that vary 
from simple severe attacks of pain, and temporary spasmodic twitching of 
muscles, up to that of complete paralysis, and often coma followed by death. 
Of course you will keep in mind that I am now speaking only of paraly- 
sis arising from non-inflammatory affections of the brain. I have already 
had occasion to point out the occurrence of paralysis in all its degrees of 
development as the result of inflammation and effusions, when speaking 
of the inflammation of the central portion of the nervous centers. Our 
present purpose, however, is simply the consideration of those of a non- 
inflammatory character. 



DIAGNOSIS. 719 



LECTURE LXXI. 



Hemiplegia fontinued— Its Diagnosis, Prognosis and Treatment; Paraplegia; Paralysis from 
Lead and Mercury, and Paralysis Agitans. 

GENTLEMEN: The diagnosis of hemiplegia, either partial or complete, 
so far as relates to the existence of the paralysis is not difficult. The 
characteristic phenomena are mainly objective and easily recognized. The 
only difficulty consists, not in deciding whether paralysis actually exists, 
but what is the nature and location of the pathological condition on 
which the paralysis depends? Whether the conditions are located within 
the cranium, and have resulted from inflammation, capillary congestion, 
hyperemia from cardiac hypertrophy, degenerative changes in the 
blood vessels, emboli, or mere reflex irritation, is not in every case easy to 
determine. 

To distinguish these cases from paralysis depending on inflammation, 
you have only to remember that the latter have a history showing all the 
phenomena or symptoms usually produced by acute or sub-acute inflamma- 
tions of important structures, such as pain, fever, or intensity of excitement 
for a longer or shorter period previous to the occurrence of the paralysis; 
while in the conditions of a non-inflammatory character, whether the 
onset be sudden or gradual, it is accompanied by no fever, or perceptible 
rise of temperature, or any one of the assemblage of symptoms which 
indicate active inflammation. To differentiate hemiplegic paralysis de- 
pendent on the cerebral lesion from those of a mere reflex character, 
which are liable to occur chiefly in hysterical, choreic, and epileptic pa- 
tients, and by some supposed to be capable of arising from reflex irrita- 
tion of worms and other disturbing influences in the alimentary canal, 
you have only to inquire carefully into the history of the patient's case. 
Such history will readily show whether there has been the existence of 
hysterical, choreic or epileptic paroxysms, and the connection- of the par- 
alysis with the supervention of the paroxysms of any one of these affec- 
tions. It may be proper to remark, however, that in addition to a history 
showing prior existence of some one of the nervous affections named, 
a hemiplegia, arising from or in connection with these diseases, is seldom 
complete. More generally it is only partial and passes away in a few days 
after a paroxysm of the affection on which it depends. 

Prognosis. — From the nature of the pathological changes I have men- 
tioned as giving rise to hemiplegia, you will infer that the prognosis, so 
far as relates to complete restoration, is very unfavorable. But few of 
these cases are in danger of immediate death on the supervention of hem- 
iplegia, while there is still less prospect that any considerable number 
will make a complete recovery. A majority recover partially, but linger 
for months and sometimes years, in an impaired condition so far as loco- 
motion and control of muscular action is concerned, and they gradually 
decline from further degenerative changes in the brain, till the final 
termination of the life. Consequently, while there is but little danger of 
immediate fatal results in attacks of hemiplegia, there is no reasonable 
prospect in a majority of cases, of reaching an entire recovery. And, if 
recovery is not reached, in process of time there occurs more or less 
softening or disintegration from degenerative changes in the portion of 
the brain affected, constituting a species of impairment of texture, and con- 



720 HEMIPLEGIA. 

sequently of function, to such an extent as to terminate the life of the 
patient. 

Treatment. — The treatment in hemiplegia is in all respects similar to 
that of apoplexy, except there is very rarely any indication for the abstrac- 
tion of blood by venesection. In a paralytic affection having originated 
from the establishment of some direct pressure upon the cerebral substance, 
such as the formation of a clot or embolus or presence of a tumor, the ab- 
straction of blood could have but little effect in altering the circulation in 
the obstructed vessels of the brain. The leading indication for treatment 
when these cases come into the hands of the physician, are, en the one 
hand, to favor as much as possible, the removal by absorption, of whatever 
material may be producing the paralyzing pressure upon the cerebral 
structure, and on the other to prevent further deterioration or impairment 
of structure in the vessels and cerebral substance constituting the seat of 
the disease, and thereby lessen the danger of renewed extravasations or 
the increase of degenerations and morbid growth. There are no better 
remedies for the accomplishment of these different purposes than those 
which I have pointed out to you in a previous lecture when speaking of 
the treatment of the different stages of apoplexy, more particularly of those 
cases that depend upon either serous or sanguineous exudation, and those 
which result from degeneration and consequent passive accumulation of 
blood in the vessels of the part, consequently it would be a needless repe- 
tition to state these remedies again at this time. So far as paralytic symp- 
toms are found associated with epilepsy, chorea and hysteria, they will be 
noted with more advantage when I call your attention especially to those 
affections. The paralysis following diphtheria, sometimes called diphther- 
itic paralysis, was considered with a sufficient degree of fullness when speak- 
ing of the sequelae of that disease in the earlier part of the present course. 
The same remark is applicable to those cases of partial or complete hemi- 
plegia, dependent upon syphilitic diseases of the membranes covering the 
brain; they having been sufficiently considered when speaking to you of 
constitutional syphilis in the class of general diseases. 

Paraplegia. — This is an affection characterized by loss of motion, usu- 
ally in both lower extremities, up to a given transverse line. That line 
may be at any point between the ankles and the armpits. A large ma- 
jority of cases of paraplegia, however, consist in paralysis of the lower 
extremities from the hips down. The paralysis may involve complete 
loss of motion, rendering both lower limbs entirely helpless and motion- 
less, or it may be only partial, rendering the movements so weak that the 
patient is unable to walk or even to maintain an erect position upon his 
feet. In very few cases is paraplegia accompanied by loss of sensation 
coincidently with that of motion, but sometimes this is the case, and in 
some very rare instances sensation alone is lost while motor power re- 
mains. Nearly all the cases of paraplegia depend upon inflammation, and 
its consequences, particularly in the development of sclerosis and other 
morbid conditions of the spinal cord. But some cases are liable to be 
met with by every practitioner, arising from pathological conditions in 
some portion of the spinal cord, of the same nature with those that have 
been described as taking place in the brain, namely hemorrhagic extravasa- 
tions, either upon the surface or into the texture of the cord, emboli plug- 
ging some of the vessels, or the development of tumors, or more frequent- 
ly thickening and induration of the membrane surrounding the cord, and 
occasionally there may be disease of the bones producing sufficient curva- 
ture to compress the cord and thus paralyze the parts below. The patho- 
logical conditions in the spinal cord giving rise to paraplegia, are the 



LEAD PARALYSIS. 721 

same in kind as those which give rise to hemiplegia when located in the 
brain. The same principles of treatment apply, as well as the same rules 
for diagnosis, as has been already stated in speaking of hemiplegia. 
These affections of the spinal cord are, however, much more rare than the 
corresponding morbid conditions taking place in the brain; and hence, as 
I have before remarked, much the larger number of cases of paraplegic 
diseases are dependent upon some grade of inflammatory action, inducing 
some degree, either of sclerosis or effusion, and consequent atrophy of 
nerve substance in the cord. Such is the case with what is denominated 
infantile paralysis, which usually attacks infants or children between the 
ages of six months and five or six years. Most such cases occur suddenly 
and involve sometimes one, but more frequently both lower limbs at the 
same time. In many the inflammatory condition yields under appropriate 
management and the paralysis disappears. In others, however, the in- 
flammatory process results in exudation, and ultimate atrophy of the nerve 
structures, more particularly those which regulate the supply of blood, 
consequently causing an arrest of the growth of the parts paralyzed, and 
leading ultimately to permanent shortening of the limb or limbs and to a 
size much less in proportion than the rest of the body. 

These cases, however, are so generally dependent on congestion or inflam- 
matory action, that their management was sufficiently indicated when 
lecturing upon the different grades of inflammation, and sclerosis of the 
spinal cord. 

Progressive locomotor ataxia, progressive muscular atrophy, were alsc 
included among the diseases of an inflammatory character, consequently 
the only forms of paralysis remaining to which I will ask your attention, 
are those arising from the effects of lead, called lead palsy, those arising 
from mercurial preparations, and some cases of paralysis agitans or shak- 
ing palsy. 

Paralysis arising from the introduction of carbonate of lead into the 
system usually comes on gradually, and in a majority of instances is felt 
first in the muscles of the fore-arm, more particularly the extensor muscles 
on the back of the fore-arm, that extend the hand, while the flexors upon 
the front of the arm remain unaffected. This renders the patient in- 
capable of lifting the hands backward, and causes them to droop or # hang 
down, giving to the disease the name of icrist-drop. While the muscles 
of the fore-arm are in most cases the first to show the paralyzed condition, 
the disease may attack almost any of t?he muscles of the body, either 
voluntary or involuntary. But it is often manifested in the muscular coat 
of the intestines, arresting intestinal evacuations and producing that 
most obstinate and painful affection of the bowels, denominated lead 
colic. The symptoms which accompany lead palsy, in addition to the 
peculiar impairment of the muscles of the fore-arm, and perhaps the arrest 
of peristaltic motion in the intestines, are a general paleness or anaemic 
hue of the patient, a rather dejected and saddened expression of counte- 
nance, feelings of lassitude, indisposition to exertion, and more particular- 
ly a blue line along the edges of the gums surrounding the teeth. This 
blue line usually occupies the thin edge of the gum surrounding the neck 
of the tooth. It is shown pretty generally in the gums of both upper and 
lower jaws, whenever the system is sufficiently affected to materially in- 
terfere with muscular action in the extremities or in the intestines. 
Besides the usual constipation of the bowels, general weakness of the 
muscles and the special loss of power in those of the fore-arm, most of the 
patients have impaired appetite, restlessness at night, and scantiness of 

46 



722 LEAD PALSY. 

urine. But the paralysis and constipation, with colic pains and the blue 
line at the edge of the gums, are the most reliable diagnostic symptoms. 
If the accumulation of lead in the system is allowed to continue and the 
patient to go without appropriate treatment, the impairment of muscular 
action may continue to increase till the patient becomes helpless, while 
the obstructed condition of the bowels leads to entire suspension of 
digestion, wich frequent turns of nausea and vomiting, accompanied by 
rapid emaciation, until complete asthenia and death result, alter a period 
of suffering varying from one to eight or ten years. Cases have occurred 
in which the lead poison affected the brain and its membranes, producing 
obscure cerebral symptoms, ending finally in entire unconsciousness or 
coma and death. The cerebral affection, however, is rare; the great 
majority of patients retaining their mental faculties throughout the whole 
course of the disease. While lead poisoning is often capable of destroy- 
ing life, yet if the further introduction of the mineral into the system is 
avoided, and the patient placed in favorable circumstances, the general 
rule is that it is slowly eliminated even without the aid of remedies. But 
the elimination may be hastened by treatment till the system becomes 
entirely free, and the patient restored to a fair degree of health. 

Prognosis. — The prognosis, therefore, is, in most cases of lead poisoning, 
favorable. 

The great majority of patients who become affected with this disease 
receive the lead by absorption through the cutaneous surface and through 
inhalation of the fine dust as it is floating in the atmosphere of the room 
in which they work. A great majority of these have become affected by 
the continuous use of white lead or carbonate of lead, particularly while 
working in doors, and those most exposed to this poison are employed 
in the manufacture of white lead. Another not very infrequent source of 
poisoning with lead is the use of cosmetics containing this mineral by 
females, under the erroneous idea of improving their complexion. I have 
met with a considerable number of cases, in young and middle-aged women 
who had not only produced a troublesome series of symptoms, consisting 
of deranged digestion and general impairment of the blood and nutritive 
processes, but had established well-marked paralysis of the extensor 
•muscles of the forearm, rendering them incapable of raising their hands 
to their heads or of doing any ordinary work. The effects were induced 
by the almost daily use of powders containing carbonate of lead applied 
pretty freely to the surface of the face and exposed parts of the neck. 

Treatment. — The first object to be attained in the treatment of such 
cases is the removal of the patient entirely from the further operation 
of the exciting cause. All handling of the carbonate of lead, or any 
preparation of lead capable of assuming the form of a carbonate, must be 
discontinued, whether in manufacturing, painting, or in using it as a 
cosmetic. And where none of these things have been the cause, it may 
be found that the patient has received his supply from water drained 
through lead pipes. If so this must be sought out and carefully avoided. 
The remedies which have succeeded best in my hands in hastening the 
elimination of the poison and thereby removing its effects, whether in the 
muscular coats of the intestines or in the voluntary muscl s of the arm or 
3ther parts, has been the use of the iodide of potassium in moderate 
doses, but persistently, for a considerable length of time. When the case 
has involved much pain, as in lead colic, I have found it beneficial to 
combine with the iodide, conium or hyoscyamus, in such doses as would 
be borne without producing dryness of the mouth, or affecting the pupil 
of the eye. Opiates are to be avoided, as far as possible, on account of 



TREATMENT. 723 

their increasing constipation and impairing, more or less, general secretory 
action. In a great majority of cases, from three to five decigrammes 
(gr. v to viii) of iodide of potassium given in solution three or four times 
in the twenty-four hours, and accompanied, when there is much pain or 
restlessness, by suitable doses of either conium or hyoscyamus, will be 
sufficient to produce marked improvement during the first week after 
commencing treatment. But to render the improvement permanent, it is 
often necessary to keep the patient under the use of the same remedies to 
the extent of from two to four doses in the twenty-four hours from three 
to six weeks. In the meantime the diet should be simple, easily digested, 
but sufficient to nourish the patient well; and as far as possible allow hirn 
to have good, pure air, and more or less passive outdoor exercise. But 
all severe exertion, both physical and mental, should be avoided when 
possible. 

Paralysis supposed to arise from mercurial preparations is much more 
rare, and generally only partial, consisting rather of paresis or impairment 
of muscular power, with more or less trembling and unsteadiness of ac- 
tion. It is to be relieved by avoiding all further introduction of the poi- 
son which has produced the disease, placing the patient at rest in good 
hygienic condition, and the moderate use of the iodide of potassium inter- 
nally. After the elimination of the poison, if there is remaining much 
debility, tonics and a more nutritious diet, and, at least, free passive exer- 
cise in the open air, will usually render recovery complete. A large por- 
tion of the cases denominated paralysis agitans or trembling paralysis 
depend upon sclerosis, or what has been called disseminated sclerosis in 
the upper portion of the spinal cord and medulla oblongata, and have 
already been considered under the head of inflammatory affections of the 
cord. Some of these cases, however, appear to be dependent upon simple 
paresis or impairment of the functions of the cord, and are associated with 
general weakness, or more frequently with the general deteriorations of 
old age. Indeed, the affection is restricted mostly to persons, whether 
male or female, in advanced life. The treatment, when dependent thus 
upon the deteriorations of age, or debility, must be simply palliative and 
supporting. Relieving the patient of mental anxiety as far as possible, 
allowing much rest in the recumbent position with short periods of pas- 
sive exercise, by riding in the open air whenever the atmospheric condi- 
tions are favorable, and such mild tonics and nutrients as the condition 
of the system may indicate in each case, constitute the best treatment. 
Xo remedies have been found to exert a very satisfactory or reliable con- 
trol, directly as remedies addressed to the nervous system, in diminish- 
ing the trembling of the muscles whenever motion is attempted. In 
many of these cases the trembling continues when the patient is entirely 
at rest, but in the greater number of instances it ceases during sleep. 
Bat, while no remedies have been found reliable, or satisfactory in their 
influence, several have been found to mitigate or lessen the degree of 
trembling and thereby to afford more or less comfort to the patient. 
Mo lerate doses of cannabis indiea, mono-bromonated camphor, chloral 
hydrate, and different preparations of valerian, are perhaps among the 
best for palliative purposes. 

Having thus reviewed the forms of paralysis, depending upon non- 
inflammatory conditions, and not connected, as sequelas, with general 
acute diseases, we will next call your attention to the consideration of 
epilepsy. 



724 EPILEPSY. 



LECTURE LXXII. 



Epilepsy— Its Varieties, Causes, Clinical Hisiory, Anatomical Changes, Diagnosis,' Prognosis 
and Treatment. 

GENTLEMEN: The morbid conditions giving rise to the phenomena of 
epilepsy, are among the most important of the functional diseases of the 
nervous system. They may be met with at any period of life, although 
they commence much more frequently in childhood and youth, than dur- 
ing adult life or in old age. They occur also in both sexes, but of those 
cases originating between fourteen and twenty years, perhaps a larger 
proportion occur among females than among males. A considerable 
number of cases of epilepsy have their beginning during infancy, being 
manifested by the occasional sudden occurrence of convulsions, from 
which the little ones quickly recover, leaving little apparent impairment, 
and which, at the time, are considered to be ordinary convulsions arising 
from teething, or from supposed irritants in the alimentary canal. Their 
epileptic character in many cases is not suspected until their re-occur- 
rence at a latter period of the child's growth. The disease is manifested 
in various degrees of severity, from a slight momentary interruption of 
consciousness, accompanied by sudden roiling of the eyes upwards, with 
a slight tremulous or irregular motion of the eye-balls, to that of a full, 
general, clonic spasm or convulsion. In some instances the disease mani- 
fests itself only in these slight momentary interruptions of the conscious- 
ness of the patient, not lasting long enough to produce a fall before they 
resume their consciousness, and oftentimes proceed directly with what 
they were doing before, as though no interruption had taken place. 
Children at play with their comrades will thus be taken, momentarily in- 
terrupting their play and allowing them to resume it again before they 
had hardly attracted the attention of those with whom they were engaged. 
These slight symptoms may occur only at intervals of several days, or 
they may occur several times during the same day. But most patients who 
become subject to these frequent slight turns, at longer intervals varying 
in the early stage of the disease from one to six or eight months, will have 
a full epileptic paroxysm, called by them a general convulsion or fit. 
There are others that seldom have these slight turns, but are subject only 
to the recurrence of the general paroxysms, at first, after long in- 
tervals, and then gradually with more frequency in proportion to the time 
of its continuance. Another mode of manifestation with many epileptics, 
is the occurrence at irregular intervals of a certain degree of vertigo, 
differing from ordinary vertigo, in being accompanied by some peculiar 
sensations originating pretty uniformly in a portion of the cutaneous sur- 
face, either upon the trunk of the body or upon one of the extremities, 
and apparently moving from its point of origin toward the head, and as 
it advances high enough to reach the neck or throat, there succeeds a pe- 
culiar sensation in the head as of an inclination to turn or fall in a given 
direction. In many instances, they will neither turn nor fall, but after 
the sensation has been experienced for a few seconds, it passes away with 
the original morbid feeling upon the surface, and they proceed with their 
ordinary train of thought or work as though nothing had happened. 

In another class of patients, I have observed that the first symptoms 
of which they complain as the direct precursor of an attack or convulsive 



SYMPTOMS. 725 

paroxysm is a choking sensation in the throat, a sensation as though 
something was rising in the throat, producing a choking and a disposition 
to swallow, and at the same moment of time a certain degree of giddiness 
or swimming in the head. The choking and giddiness both subside often 
without entirely suspending the consciousness of the individual, or pro- 
voking anv spasmodic manifestations; but at longer intervals these same 
phenomena are followed by entire unconsciousness, and more or less of gen- 
eral spasmodic action. I have mentioned these different modes of manifes- 
tation of the disease, because they are often noticed in children for a con- 
siderable period before the full development of the disease, as indicated 
bv the occurrence of a general convulsive paroxysm. And if they were 
duly recognized and understood, it would give the family and physician 
opportunity to commence treatment much earlier and with better pros- 
pect of success than when they are overlooked and neglected till the 
disease is more fully developed. From what I have already stated, you 
will infer that the active manifestations of disease are not continuous in 
the epileptic, but occur strictly in paroxysms. While they are parox- 
ysmal, however, there is no near approach to regularity in the periods of 
time at which the paroxysms come on in a large majority of the cases; 
neither is there any particular time in the twenty-four hours that the 
disease manifests itself with any uniformity, yet, judging from my own 
observation, I would regard it as correct to state that at least two-thirds 
of all the cases of epilepsy manifest their severe and full paroxysms, 
especially during the first two or three years progress, in the night time 
or early in the morning. In some cases the paroxysm is most apt to 
occur after the first hour of sound sleep, in the early part of the night. 
But in a much larger number, the convulsive paroxysm makes its appear- 
ance in the last part of the night or on first rising in the morning. 
Another law, which seems to be a pretty uniform one, is that when the 
disease has once commenced, if it is not interfered with by treatment, 
there is tendency to shorten the interval between the recurrence of the 
paroxysms, with increasing ratio, the longer the disease continues. 
Hence, you will often meet with cases in which, in the early stage of the 
disease, the patient had but one or two paroxysms in a year, leaving an 
interval of six, and sometimes eight or even ten months between their recur- 
rence, with hardly a perceptible minor symptom of any kind in the inter- 
vals. But at the end of live or six years they will be recurring in full parox- 
ysms every month, and sometimes two or three times a month, with the minor 
indications, such as momentary suspension of consciousness, or spasmodic 
motion of the eyeballs, eyelids, or momentary turns of vertigo, and chok- 
ing sensations in the neck almost every day. The disease thus continues, 
manifesting its active paroxysms more and more frequently, and at the 
same time producing more decided deteriorative effects upon the mental 
manifestations of the patient, as well as upon his physical movements. 

Symptoms. — In describing more minutely the symptoms accompanying 
cases of epileptic disease, I may remark, that there is no uniform temper- 
ament, or physical conformation which belongs to the epileptic patient. 
But the disease may be met with in temperaments of the most diverse 
character. Some patients suffering from this disease will have short necks, 
broad chests, an active, sanguine temperament, and exhibit all the marks 
of good nutrition, and a good degree of physical strength and hardihood. 
Others will exhibit a pale, anaemic hue of the surface, spare muscles and 
limbs, narrow chest, long necks, and the very opposite of the sanguine, or 
bilious temperament, the nervous and anaemic. And I think it not incor- 
rect to say, that you will find almost every gradation of difference between 



726 EPILEPSY. 

these two extremes. The phenomena of the disease may be considerec 
under two divisions: one belonging- to the patient between the paroxysms 
and the other the symptoms that accompany the full active paroxysm it- 
self. In the early stage of the disease, which may be said to cover a pe- 
riod varying with different patients from six to eighteen months, there 
are often no symptoms in the interval between the general paroxysms, in- 
dicative of any morbid condition whatever. Jn others, however, there is 
during this early period, in the interval between the full paroxysms, an 
unusually excitable condition of the patient, especially in reference to the 
excitement of the more violent passions. If in childhuod, they are often 
regarded as passionate, ill-tempered, difficult to govern, and often more 01 
less disturbed with dreams and startings during the night. As a rule, the 
appetite is stronger than in good health, especially the appetite for some 
of the more rich and nutritious articles of food. Sometimes this exists to 
such an extent as to merit the name of voracious appethe. The evacua- 
tions from the bowels are seldom different from that of health, unless there 
be in some cases moderate constipation. The urinary secretion is usually 
normal in quantity and quality. After the disease has existed for a long 
period of time, there will almost always be in the intervals between the 
full paroxysm more or less of a sudden supervention of momentary loss 
of consciousness, or periods of giddiness, and feelings described as aura. 
creeping sensations over some portion of the surface, and a sense of 
choking in the neck; but very variable in the frequency of their occur- 
rence, and in the time of day that they may be noticeable. The symp- 
toms which characterize a direct, fair paroxysm of epilepsy, though varying 
much in severity and the duration of the paroxysms, are nevertheless suf- 
ficiently uniform in their essential characters to be easily understood. 
The onset is generally sudden, sometimes without any premonitory sensa- 
tions. The first noticeable feature will be, if the patient is awake and 
within observation, a sudden arrest of all motion, except in the face and 
head; the latter is thrown a little back and the lace upward with a jerk- 
ing, irregular motion, and usually slight twitching of some of the muscles 
of the face, and in a second or two, the jerking extends throughout the 
whole voluntary system of muscles, causing- all the phenomena of genera) 
spasms or clonic convulsion, arresting respiratory movements, causing the 
face to become extremely turgid with blood, the jaws alternately clinched 
and open, not infrequently allowing the tongue to be caught between the 
teeth and bitten; sometimes also folds of the inside of the cheeks and 
lips, lacerating them sufficiently to cause more or less of a flow of blood 
with the frothy saliva from the mouth. When the convulsion has 
held the respiratory movements in check long enough to cause the 
face and lips to become purple and swollen, and the pupils a little di- 
lated, the accumulated carbonic acid gas in the blood, and absence of oxy- 
gen, overwhelms the sensibility of the nervous system to such a degree 
as to arrest the further spasmodic action; then the muscles pretty rapidly 
relax, the patient begins to catch his breath, at first with a loud rattling 
noise, from the sudden forcing of the air through the mouth and throat 
which contains more or less viscid mucus, and as the air is forced suddenly 
in and out, an abundance of frothy saliva, often tinged with blood from 
the bitten places in the tongue and cheeks, is expelled from the mouth, which 
with the rattling noise, acids much to the feelings of terror created in the 
bystanders. But in two or three minutes the patient has gained sufficient 
regularity in breathing to again oxygenate and decarbonize the blood; 
the turgid, or dark purple hue of the face recedes rapidly, and gives place 
to a more natural color, and in the space of three to five minutes, or less, 



SYMPTOMS. 727 

the patient lias passed into a condition in all respects resembling profound 
sleep. The breathing is nearly regular, color of the face natural, and all 
the muscles relaxed. 

If the patient is undisturbed, in a majority of instances this apparent 
sleep will continue a period of time varying; from fifteen minutes to one 
or two hours, when he will spontaneously awake entirely conscious, 
but with a look of surprise as though for a moment not aware of where 
he was or what had happened. But he almost immediately recognizes his 
position, and if not interfered with, gets up at once, takes up whatever 
lie had dropped at the time the convulsion seized him and goes about his 
ordinary previous work, whatever it might have been. All of these pa- 
tients thus have a period of quiet and apparent sleep following imme- 
diately a full convulsion. Most of them can be aroused out of this sleep 
at a much earlier period by shaking them, dashing a little water upon the 
face, and friends will almost always do this from aYixiety to bring them to 
consciousness. It is better, however, to al ow them to remain entirely at 
rest until they awake spontaneously, so far as the wellfare of the patient 
is concerned. While many patients are thus seized with fits suddenly 
without any premonition, there are many others, who as uniformly have 
certain premonitory feelings that warn them regularly of the approach of 
the paroxysms. The most common of these premonitory symptoms are 
sensations of a somewhat peculiar character, generally described as aura. 
It is a creeping sensation, not distinctly cold perhaps, but such that the 
patient, after feeling it once or twice, recognizes fully its meaning. It 
may begin at any part of the cutaneous surface, more generally either up- 
on some part of the arm or leg, and frequently in the epigastric region. 
But wherever it may commence, the movement of the sensation is at a 
pretty uniform rate directly upward toward the neck and head. And 
it is usually not more than two or three minutes, and sometimes not as 
many seconds, from the commencement of the sensation before it has 
reached the neck and there uniformly produces a choking feeling, imme- 
diately followed by an arrest of consciousness. ^Yith the commencement 
of the jerking convulsive motions that I have already described, if the pa- 
tient is in the standing position or sitting, he immediately falls prostrate, 
wherever he may be, and not infrequently suffers much harm from inju- 
ries produced by falling on hot bodies, or upon hard substances, and if 
grown to maturity, sometimes falling from stairs, windows, or other high 
places, producing the most disastrous consequences. But the same 
phenomena take place if the paroxysms approach while the patient is 
in bed and in profound sleep. This peculiar sensation commencing up- 
on some portion of the surface and proceeding in a regular line toward 
the neck and head, is denominated in the books, epileptic aura. There 
are other cases, which instead of commencing with the aura upon the 
surface, will pretty uniformly have a distressed feeling of fullness, like 
gaseous distension of the stomach, or a positive pain in the epigastrium. 
This pain, commencing in the epigastrium, extends like compression or 
tightness up through the chest as though it would stop the respiratory and 
circulatory movements, but quickly, on reaching the upper part of the 
chest and neck, is superseded by sudden loss of consciousness and the 
development of the spasmodic phenomena of a paroxysm. In whatever 
way a full paroxysm of epilepsy commences, whether with or without 
premonition, there is perhaps with great uniformity a loss of sensation or 
the suspension of consciousness, with more or less general spasmodic 
action throughout the muscular system. 

AVith this general cessation of the consciousness of the patient, the 



728 EPILEPSY. 

time, from that moment till waking after the paroxysm has ceased, re- 
mains an entire blank, the patient having no recollection or consciousness 
of anything that transpired, or even of his existence during the interven- 
ing period of time. Another characteristic that is pretty uniform, is the 
suddenness with which consciousness returns after the paroxysm has 
ceased. In most other morbid conditions of the brain and nervous 
centers, accompanied by unconsciousness, the recovery from the uncon- 
sciousness is more or less slow and oftentimes imperfect. But with the 
epileptic, on the cessation of the paroxysm, he is seldom awake or aroused 
to any recognition of anything more than a few seconds, before this con- 
sciousness is apparently as complete as in health. There is apt to remain, 
however, more or less of a feeling of discomfort and strangeness through 
the head for several hours after the occurrence of a full attack. In many 
there is a dull, heavy pain in the head for the greater part of twenty-four 
hours. It will, also, often happen not only that there is dull headache 
with pressure and dizziness following the paroxysms, but an increased 
dullness of mental operations and inability to remember well, for two or 
three days after each paroxysm. This is generally not the case until the dis- 
ease has advanced far enough to begin to alter, more or less, the nutritive 
function in the nervous centers. While such are the characteristic symptoms 
of the paroxysm, and the general phenomena the patient exhibits during 
the intervals from one paroxysm to the next, in the larger proportion of 
cases of epilepsy that have their beginning in childhood, the paroxysms 
not only tend steadily to recur more frequently, but the disease is accom- 
panied by very gradual impairment in the nutrition, and consequently in 
the manifestation of the functions of the brain. So true is this, that very 
few individuals who commence the disease in early childhood and con- 
tinue with it gradually increasing in the frequency of its paroxysms till 
they have passed the period of puberty, escape having the mental faculties 
decidedly impaired. In most cases, memory becomes unreliable, the 
appetite and passions of the patient fickle or variable, and sometimes 
altogether uncontrollable. Their sleep is more or less disturbed, appetite 
for food voracious, intellectual operations slow and often subject to inter- 
ruption giving a noticeable disconnectedness to their expressions, while 
their passions and emotions become much more prominent and more 
easity excited to violence. As the disease progresses still further, each 
year adds to their mental impairment and loss of self-control, until in many 
instances, before they have arrived at adult life, they become apparently 
demented, with a peculiar expression of countenance, usually drooping at 
the angles of the mouth, allowing much of the time the saliva to flow 
out uncontrolled. At length there come also impairments in the power of 
speech and of deglutition, requiring care to avoid choking in taking food, 
and ultimately a condition of entire imbecility and helplessness, in which 
the patients pay little or no heed to the evacuations either of urine or iseces, 
and retain not sufficient mental capacity to feed themselves or to exercise 
the least care over their most necessary daily needs and habits. In castas 
where epilepsy has commenced in infancy and the paroxysms have be- 
come frequent from that time up to five, six or eight years, they are very 
liable to be accompanied by partial arrest in the growth of the brain, 
causing the brain, anteriorly at least, to be narrow, and the whole head to 
be below the normal size of development proportionate to their age. 
Where this is the case, it is almost always accompanied by a correspond- 
ing enfeeblement of mind or entire imbecility. 

When the epilepsy commences at a later period in life or after the 
time of puberty, it is seldom accompanied in its progress by such 



CAUSES 72 ( J 

alterations in nutrition, and in mental manifestations as we have just de- 
scribed. Yet, even in such cases, it may induce much weakness and the 
paroxysms come so often as to destroy the usefulness of the patient al- 
together in any pursuit of life, and to impair somewhat the memory and 
the control of the reasoning faculties over the passions. Still it is rare 
that it reduces them to that state of imbecility which very frequently re- 
sults when the disease has commenced in infancy and i$s paroxysms be- 
come frequent in recurrence through early childhood. There are some 
instances where the disease has commenced its first manifestations at or 
after puberty, in which the patient seldom manifests a perceptible im- 
pairment of any of the mental faculties, not even after the disease has 
continued for twenty or thirty years. 

Causes. — In the great majority of instances, no well ascertained cause 
or causes can be identified as having originated the disease. During in- 
fancy and early childhood, the popular mind will attribute all the earlier 
paroxysms either to teething, to worms in the alimentary canal, or a little 
later during early childhood, to intestinal irritation and indigestion. But 
it is very doubtful whether any of these causes are operative in a large 
majority of all the cases of epilepsy that occur at the early period of life. 
Hereditary influence undoubtedly exists in many cases, and in a large 
proportion of them, due inquiry would develop the fact that the parents 
or ancestors in some part of the family line had been subject more or less 
to the disease. There are some statistics which would lead to the infer- 
ence, that children born of parents who have become strongly addicted 
to the excessive use of alcoholic drinks, are more subject to attacks 
of epilepsy than those born of parents not addicted to the same practices. 
The use of alcoholic drinks on the part of young persons and some- 
times at any period of life appears to incline, or predispose to attacks of 
epilepsy, but only to a limited extent. In females there are a considerable 
number of cases that have had the beginning of their occurrence with 
the period of the first manifestation of menstruation, the paroxysm of 
epilepsy coming at such time as to identify it uniformly with the menstrual 
flow. With some the epileptic paroxysm will immediately precede the 
commencement of the monthly sickness; in others it occurs during the prog- 
ress of the flow but in the larger number, the attacks develop from one to 
three days after the cessation of the flow. When the disease occurs in con- 
nection with the monthly flow, and its paroxysms are rarely noticed to oc- 
cur in the intermediate time, it is fair to presume that there is some morbid 
sensitiveness in the uterus or its appendages, that is increased by the de- 
termination of blood and greater fullness, as the menstrual flow approaches, 
until it extends a reflex influence through the spinal cord to the base 
of the brain, and thus develops an epileptic paroxysm. In the 
male it is supposed that the practice of self-abuse and excessive sexual 
indulgence in any mode, during the period intervening between fifteen 
and twenty years, is liable to constitute an exciting cause of epilepsy. 
I am not satisfied, however, that any cases have occurred under my own 
observation, in which this was the primary cause. I have no doubt, 
however, from observation, that where the predisposition exists and where 
the disease has already been established, that excessive sexual excitement of 
any kind has a decided influence in increasing the frequency of the 
paroxysms, and aggravating the disease. Another not infrequent cause of 
epilepsy, is injury to peripheral nerves by mechanical violence. There 
are many cases on record, where from injuries of various kinds, and some- 
times surgical operations, a sentient nerve has been included in the cica- 
trix, left by the healing of a wound, in such a way as to cause a reflex influ- 



730 EPILEPSY. 

ence to be extended to the nervous centers, and to be a direct excitino 
cause of epileptic paroxysms. 

Among the most common of the injuries which result in epilepsy, are 
those inflicted upon the scalp, or upon the bones of the cranium. I have 
seen several instances where mere scalp wounds, after they had healed 
and appeared to be entirely well, were found to exhibit a certain degree 
of tenderness on pressure, and th? patients became subject to paroxysms 
of epilepsy, and the complete removal of the cicatrix has been followed 
by cure of the disease. Fractures of the cranium that occur from 
blows or severe mechanical violence, though not displacing the whole 
thickness of bone sufficient to produce compression of the brain, may so 
far shatter the inner table of the skull as to cause a little spicula of 
bone to be depressed inward, in such a way as to have its point rest upon 
the dura mater and become a source of irritation, and to be followed by 
the development of epileptic paroxysms, usually of considerable severity. 
That the effect of the bony fragment, in irritating the membrane and 
surface of the brain, was the true cause of the epilepsy, would seem to be 
proven by the fact that when the scalp has been laid open, and the in- 
jured portion of bone removed with the trephine, the patient ceased to 
have any further paroxysms of epileptic disease, and in many instances 
recovered good health. You will see from the tenor of what I have said, 
that so far as the etiology of epilepsy is concerned, the causes may be 
divided into two classes, namely, those that affect primarily the periph- 
eral extremity of sentient nerves, producing epileptiform disease only 
by reflex action upon the nervous centers, to which belong the cases that 
arise from uterine and ovarian irritations, intestinal disturbances, wounds, 
cicatrices, and fractures of the skull, and which are properly denominated 
reflex cases of epilepsy. The other class of causes act directly upon the 
cerebral hemispheres and ganglia at the base of the brain, producing 
primary changes there, and consequently they are not reflex but direct in 
the order of phenomena, the causes being such as produce some modifi- 
cation of the properties and functions of the cerebral substance, instead of 
acting upon the peripheral extremity ©f nerves. Following this division 
of causes, some writers have divided epilepsy into two groups of cases; 
one of whioh they denominate cerebral, and the other peripheral, or 
centric and excentric. By the first, they mean those cases which 
originate from primary irritation, or morbid action in the nervous 
centers, generally in the ganglia at the base of the brain, or in the 
surface of the hemispheres, or both. While by peripheral cases are 
meant those in which the primary point of irritation involves some sen- 
tient nerve at its extremity, as I have explained only a few moments 
since. It is well to keep in mind these two classes of cases, as it will aid 
you, both in devising rational modes of treatment for individual cases, 
and in judging of the prospects of amelioration or cure. As a rule, 
peripheral or reflex cases of epilepsy are for the most part curable, if the 
treatment is commenced at an early period in the progress of the disease, 
and judiciously continued for a considerable period of time, while in the 
great majority of cases of central epilepsy, or such as have their origin 
from direct irritation of the sentient portions of the base of the brain, and 
periphery of the hemispheres, the prognosis is not favorable; neither is 
it necessarily and uniformly unfavorable; but the number of cases of this 
class that recover is small, compared to the whole number that occur. 
And while the prognosis in cerebral epilepsy is very generally unfavor- 
able so far as relates to the ultimate recovery of the patient, it is not un- 
favorable so far as relates to any immediate danger to life; for life may be 



ANATOMICAL CHANGES. 731 

prolonged through many years, as I have previously explained, or until 
the patients have become imbecile, or even idiotic, from impairment of 
the cerebral structure, instead of being cut off by any acute disease. 



LECTTJKE LXXIII 



Epilepsy continued —Its Anatomical Changes, Diagnosis, Prognosis and Treatment 

GENTLEMEN: In considering the anatomical changes accompanying 
epileptic disease, it must be remembered that uncomplicated epilepsy 
seldom terminates fatally in any of the earlier stages of the disease, 
consequently opportunities for post-mortem examination of patients in 
the early periods of the progress of the disease, are afforded only by acci- 
dent or through death from some other cause. When such opportuni- 
ties have occurred, in most instances the changes apparent to the 
eye, in any part of the nervous system, are not sufficiently distinctive 
to indicate any special anatomical lesion as belonging to this disease. If 
the disease has existed for a long period of time, examinations usually 
show some degree of dilatation of the blood vessels in some part of the 
medulla oblongata, or pons varolii, and occasionally in other portions of 
the cerebral structure. In cases where the disease has existed for a long 
series of years, as in those subject to the disease from childhood to the 
middle and later periods of adult life, some portions of the medulla, cru- 
ra-cerebri and parts o'' the base of the brain have been found denser 
than natural, the convolutions somewhat atrophied, giving to the lower 
part of the anterior lobes less transverse diameter than is natural. These 
extreme changes are usually seen only in cases which have existed from 
childhood, and are the result of relatively diminished growth or develop- 
ment, leaving the patient in a state of more or less dementia or mental 
imbecility. Such cases, before death, present an unusual smallness of the 
anterior portion of the cranium, particularly through the base and lower 
part of the anterior portion, while the cerebellar and occipital regions and 
posterior parietal parts maintain more nearly their natural size and per- 
fection of nutrition. Notwithstanding all the investigations of the emi- 
nent neurologists of the present day, it can hardly be said that any lesion 
of the nervous centers, or anatomical changes have been found sufficiently 
cons'ant to justify their being regarded as peculiar to, or especially char- 
acteristic of the epileptic form of disease. Such experimental physiol- 
ogists as Marshall Hall, Brown-Sequard, Charcot of Paris, and not a few 
in our own country, have thrown much light, by their experimentations 
upon animals, upon what we might denominate the mechanism of epi- 
lepsy, or the different causes by which the paroxysms may be induced, and 
have, perhaps, pointed out more nearly and accurately the particular por- 
tions of the nervous centers that are usually involved functionally. And 
yet they have not arrived at a satisfactory development of any peculiar 
anatomical lesion. While there may be no special structural changes, how- 
ever, which can not be found in connection with other manifestations of dis- 
ease besides that of epilepsy, the special nature of the morbid process, 
which essentially constitutes the epileptic disease, may be defined to be a 
morbidly excitable condition of the medulla oblongata and the common 



732 EPILEPSY. 

center of voluntary motion at the base of the brain, coupled with im- 
pairment of the normal control of the cerebral hemispheres over the 
involuntary or excito-motory functions of these central parts. The con- 
stant morbid condition belonging essentially to the pathology of the dis- 
ease, is undoubtedly an undue or exaggerated excitability or susceptibil- 
ity of the nervous centers of voluntary motion. This morbid excitability 
of the structure places it in a condition favorable for the action of any 
exciting cause, whether acting through the mental faculties in direct con- 
nection with the cerebral hemispheres, or by an excito-motory or reflex 
influence, from irritation transmitted from some morbid condition, or irri- 
tant action, at the peripheral extremity of the sentient nerves. 

And if the expression of Hughlings Jackson, that the active paroxysms 
of the disease were the result of irregular discharges of nerve force in 
the cerebral centers, is meant to convey the idea that the transmission of 
some exaggerated impression, either through the mind or through periph- 
eral nerves to the cerebro-spinal axis, previously in the state of morbid 
excitability that I have mentioned, and in consequence, carrying the motor 
function beyond the control of the mind or cerebral hemispheres, and 
thereby inducing involuntary, clonic, uncontrollable spasmodic action, 
together with loss of consciousness, as exhibited in ep'leptic paroxysms, I 
can assent to the explanation. While I would regard the morbid sensi- 
tiveness of the portion of the cerebro-spinal axis to which I allude as 
the essential and constant pathological condition constituting the epilep- 
tic disease, it is true that the coincident conditions of other functions 
differ widely in different patients. In one, morbidly excitable nervous 
centers may co-exist with a sanguine temperament, a well nourished con- 
dition of the system, full development of the muscular structures of the 
body, and in all respects vigorous physical health, and may produce in 
such epileptics, convulsions at the usual periods with as much violence as 
in any other class of cases with which I have come in contact. In a 
much larger number, however, this morbid condition of the cerebro- 
spinal center is associated with a condition of the physical system more 
especially marked as the nervous temperament, deficient rather in the 
performance of the assimilative and nutritive functions, leaving the 
blood below the normal proportion of red corpuscles, tissues generally 
pale or inclined to moderate emaciation and thinness of flesh. And this 
tendency to paleness or anaemia and diminished nutrition appear to in- 
crease slowly with the increase in the duration of the disease. 

Treatment. — Epilepsy being a disease which has attracted the attention 
of the physician from a remote period of antiquity, and in the early ages 
not infrequently regarded as the manifestations of demonism, the remedies 
which have been brought into requisition for its treatment are perhaps more 
numerous and have been applied more empirically, than in the treatment of 
any other disease in the whole catalogue of human ailments. I shall not, 
however, tax your time by enumerating the long list of remedies that 
have been tried, recommended and abandoned in turn, but will simply 
give you such as the modern investigations, and my own experience in 
the treatment of this variety of disease lead me to regard as most impor- 
tant. At the time I entered upon the practice of medicine, little less than 
half a century since, the two leading remedies for the treatment of 
epilepsy were nitrate of silver and sulphate of zinc. The former, more 
especially, was very extensively used, and at that time it was not very un- 
common to meet with cases in which it had been administered for such a 
length of time, and in such doses, that it had found its way through the 
blood to the cutaneous surface, where, acted upon by oxygen and light, 



TREATMENT. 7 






it had produced a noticeable change of color in the skin. But the most 
ample experience has demonstrated that the nitrate of silver, sulphate of 
zinc, and a long list of other agents heretofore used more or less, are 
altogether useless, or productive of no curative results. Since the more 
recent studies concerning the nature and phenomena of epilepsy has 
seemed to establish the fact that the disease is one primarily of morbid 
excitabilitv of the nervous centers, the attention of the profession has 
been turned almost exclusively to the use of those agents which are prop- 
erly styled nervous sedatives; such as the bromides, physostigma, 
digitalis, gelseminum, chloral hydrate, etc. Cases are met with in which 
all these remedies exercise a certain amount of influence in rendering the 
active paroxysms of the disease less frequent and less severe, at least for 
a considerable period of time; and, yet, in only a small proportion of the 
whole number are they found to produce any permanent interruption of 
the paroxysms, or to make a final cure of the disease. 

Formerly, it was the habit to speak of the treatment of the disease un- 
der two divisions: one appropriate in the paroxysms, or during the period ot 
active convulsive movements, and the other, required in the intervals, with 
a view of preventing the recurrence of the paroxysms. But, practically, 
there is no need of medical treatment or attempted medical treatment 
during paroxysms of epilepsy. As I have stated, when speaking of the 
symptoms and clinical history of the disease, the convulsive paroxysms 
are always temporary in their duration. Just so soon as by the arrest of 
respiration, the oxygenation and decarbonization of the blood is inter- 
rupted long enough, it renders that fluid sedative to the excitability of 
the brain, and consequently the active convulsive movements of the par- 
oxysms seldom continue more than from two to five minutes. There is, 
therefore, neithe.- time nor necessity for any active treatment of the par- 
oxvsms. Placing the patient in a recumbent or inclined position, 
with the clothes loosened sufficiently to prevent any undue pressure upon 
the chest or interference with the respiration, by opening the collar and 
necktie, leaving the neck, larynx and throat bare, and free access of air for 
the patient to breathe, constitute the only measures of any value during 
the active convulsive paroxysms. When the paroxysm has ceased, it 
should not be assumed that there is nothing to be done but simply to 
prescribe some favorite remedy which is supposed to exert a specific influ- 
ence over the nervous excitability. This is too much the habit of a large 
proportion of the profession at the present day. Epileptic patients, on 
the contrary, need to be examined as carefully, and to be prescribed for 
as fully, not merely in relation to medicines to be taken, but in relation 
to their diet, dress, exercise and all the habits of life, as patients laboring 
under any other form of disease. If this attention is given them, and the 
treatment commenced early, while the intervals between one paroxysm 
and another is still long, and the measures persevered in for a number of 
months, a considerable proportion of cases can be cured, or at least all 
active phenomena of the disease suspended for a series of years. It is 
very important, when taking charge of any case of epilepsy, that careful 
inquiry be made in regard to the condition, or habitual performance of 
the functions connected with the digestive organs, and such measures as 
may be necessary should be instituted and carefully carried out for keep- 
ing the movements of the bowels as near the healthy standard as possible, 
neither allowing constipation on the one hand, or active purgation on the 
other, but such use of laxative and tonic medicines, and such articles of 
diet, as will promote most nearly a strictly, regular, healthy condition, 
both of digestion, secretion and evacuations. And in this connection 



734 EPILEPSY. 

more attention also should be given to the function of the kidneys than 
is ordinarily done. 

In some instances it will be found that the skin and kidneys are defi- 
cient in eliminating waste material, and that one needs prompting by 
diuretics, and the other by a warm alkaline bath twice a week, followed 
each time by brisk active friction with dry flannel. The exercise of 
this class of patients also should be regulated in such a manner as to se- 
cure a good degree of outdoor daily exercise, but without violent or 
protracted exertion. Mental application also should be carefully regu- 
lated, avoiding intensity of study or mental exercise in the young, or in- 
tensity of business application and anxieties in those in mature life. 
And yet equally, if possible, avoid leaving the mind, either of the young 
or middle aged, unoccupied. Both excessive mental activity, especially if 
accompanied with mental anxiety and depressing influences, and mental 
ennui or want of employment or occupancy, are unfavorable and directly 
calculated to increase and perpetuate the disease. Another item perhaps 
of quite as much importance even as a most careful selection of medi- 
cines, is the regulation of the diet. Many years since, the elder Dr. Jack- 
son, of Boston, if I remember rightly, mentioned in some of his writings 
that the avoidance of meat, and adherence to a milk and farinaceous or 
vegetable diet was desirable and sometimes at least very beneficial in 
lessening the frequency of the epileptic paroxysms. Through the many 
years that have since passed, I have had occasion to note the influence 
exerted by using meat freely as an article of diet, and also by abstaining 
from it, in various stages, in the progress of this disease. I am fully satis- 
fied from such observation, that in a large proportion of epileptics, all of 
them in fact, except those that are most anaemic, it is decidedly advan- 
tageous to have them abstain either entirely from the use of flesh meat as 
food, or to allow only a very limited amount at the dinner hoar each day. 
I remember one case of well marked epilepsy, which had continued, the 
paroxysms gradually increasing in their frequency, for more than three 
years, in the person of a young man of a nervous temperament, neither 
strongly anaemic nor plethoric, who hid been treated during much of the 
three years, with the usual degree of skill, so far as medicines were con- 
cerned, by a number of physicians of good standing, but without any 
apparent progress in ameliorating the condition of the patient, or in 
lessening the frequency of the paroxysms of the disease. He was tired of 
taking medicine, protested against its continuance, and I suggested that 
he at least adopt a moderate and regular daily routine of outdoor exer- 
cise, taking pains to exercise the arms and muscles of the chest, with 
sufficient mental occupation to furnish the mind with at least diversion 
and occupancy, but without any severe tax upon its activity, take no med- 
icine and omit entirely the use of meat from his diet. He was allowed 
as much as his appetite required, of milk, different varieties of bread, 
ordinary variety of vegetables, but avoided all stimulating drinks of 
every kind fermented and distilled, as well as tea and coffee. 

He followed the advice faithfully, and after the first four months he 
ceased to have any recurrence of his epileptic paroxysms, and although his 
future progress was noted through a period of five or six years, he con- 
tinued to have good health and entire freedom from any recurrence of 
epileptic paroxysms. It is not the object, you will perceive, to confine 
patients to a low diet, in the proper sense of the word, for we allow full 
liberty to use what the appetite demands, and that of a sufficiently wide 
range or variety in its constituency; but simply exclude meat and those 
drinks which are known to increase the excitability of the nervous sys- 



TREATMENT. 735 

torn. There are some cases, however, of epilepsy in which the patients 
have already become decidedly anae.nic, with cold extremities, tempera- 
tare habitually one or two degrees below the natural standard of health, 
pulse soft, weak, and yet subject to epileptic paroxysms of more or less 
frequency and severity. In such, instead of prohibiting entirely the use 
of meat, I think it advisable simply to regulate the amount, causing them 
to take but a moderate proportion of the more nutritious and easily 
digestible varieties of meat with their breakfast and dinner, omitting it al 
the evening meal. In this class of subjects, wherever it can be done 
with sufficient degree of perseverance to render it worthy of trial, I re- 
jnr-ard the use of electricity, or rather galvanism, with some degree ol 
frijtion or massage, as an important part of the treatment. The galvanic 
current should never be communicated to them with sufficient intensity tc 
c iuse shocks or direct excitement, but in the way best calculated tc 
promote general nutrition by its influence in quickening the functions of 
what a r e termed the trophic or vaso-motor nerves, and the inherent affinity 
of the primary molecules that enter into the structure of the tissues o] 
the body. To make this available in the greatest degree, the remedy 
should be used from five to twenty minutes once a day, or at least every 
alternate day. You will note that this recommendation in reference tc 
electricit/ or galvanism, with friction and massage, is only made as 
applicable to those cases that have become anaemic and deficient in gen- 
eral nutrition. For many epileptics are abundantly nourished, and eight 
out of ten of all of them have voracious appetites, and especially appetites 
for beefsteak and other items of rich food. In regard to remedial agents, 
none will be of much value except such as I have alluded to for regulat- 
ing secretions, promoting a healthier condition of functions that may be 
defective, unless they be used with steadiness for a long period of time. 
And this is one of the greatest sources of failure in the treatment of this class 
of cases. The disease manifests its active phenomena only in paroxysms. 
In the earlier stages of their progress, they come not oftener than once in 
every four, six or eight months. In the intervals, much of the time, the 
patient has the appearance of entire good health. It is extremely difficult 
in such instances to have either parents, in reference to their children, or 
a lult patients themselves realize that there is any necessity for using reme- 
dies from day to day, while apparently as well as any of those around them. 
A I are ready enough to take medicine when the paroxysms of convul- 
sion come, and to follow it up for a week or possibly two or three weeks 
after it has passed by; but to persevere in all these matters judiciously, 
from month to month, is what the large proportion of them will utterly 
fail to do, notwithstanding your most careful explanation of the nature oi 
the disease and the necessity for such perseverance. These remarks are 
especially applicable to the treatment of the earlier stages of the disease. 
There are many cases, after they have continued five, six or a dozen 
years, and increased in the frequency of their paroxysms from once or 
twice in the year to a paroxysm every week, with visible impairment of 
the mental faculties, in which the anxious parents and friends will often 
persevere in the use of medicine until the system may be saturated even 
to an injurious extent. But at such advanced stage of progress, most 
cases of epilepsy prove to be absolutely incurable. They are often 
palliated and the paroxysms postponed to longer intervals between their 
recurrence. And, although, a great many of these confirmed cases have 
come under my observation, I have known but very few in which the 
disease has been permanently interrupted. If the disease is taken in 
charge in young subjects anywhere from infancy to five or six years of 



736 EPILEPSY. 

age, and before structural lesions or partial arrest of nutrition in the 
cerebral centers has actually taken place, a considerable percentage may 
be cured. I speak the more positively, that a proportion of them may be 
cured, as I have known some long enough to know personally that the 
disease had remained without any recurrence from childhood, at least, to 
the middle period of adult life. 

I do not yet think there is a specific remedy for the cure of epilepsy; 
but the particular combination which has proven more serviceable in my 
own hands than any other, although I have tried a great variety — is that 
of one of the bromides, given in connection with the fluid extract of g ilium 
alba, and a certain proportion of digitalis. I say one of the bromides, be- 
cause I think as a general rule, there is no advantage in combining the 
different bromides together, but there are some patients that will be bene- 
fited to a greater degree by the bromide of potassium, others by the 
bromide of ammonium, and still others by the bromide of lithium. It is 
not easy to determine which of these will do most good to the patient 
until they are tried. I have thought this rule applicable: that in those 
cases where there is a tendency in connection with the disease to inactivity 
of the kidneys, inclining the patient habitually to scantiness of urine, the 
bromide of lithium was found most beneficial. And in such I also give 
in connection with the bromide and galium, such doses of the wine of 
colchicum root as can be borne without disturbing the bowels, instead of 
digitalis. But in the large majority of cases, I have thought the bromide 
of potassium the more efficient article of this group. The formula which I 
have used much for the last twenty years consists of the bromide of potas- 
sium twenty-five grams (3vi) tincture of digitalis, twenty-five c. c. (fl 3vi) 
fluid extract of galium alba, ninety c. c. (fl §iii), and simple elixir thirty 
c. c. (fl |i). To an adult or person above the period of puberty, I have usually 
given of this formula, four cubic centimeters (fl 3i) before breakfast and 
supper, and six cubic centimeters (fl 3>ss) at bed time. If the paroxysms 
of the disease recur at long intervals, it is sufficient in many instances to 
give but two doses a day, i. e. four cubic centimeters (fl 3i) in the morning 
and six (fl 3iss) in the evening. I have found it, however, advantageous, 
whenever the paroxysms of the disease have been found to recur with 
a sufficient degree of regularity so that it could be known about when 
the next paroxysm was to be expected, that the patient should com- 
mence at least a week before the time, to increase the medicine to three 
doses every day instead of two, and continue it at that rate till the time of 
the expected paroxysm had passed by. Then recede again to a dose 
morning and evening. In prescribing for younger persons the same com- 
bination may be used, but the dose must be diminished at the ordinary 
ratio to keep the proportion appropriate for the age of the patient. The 
reason for giving larger doses at night is, that a large proportion of epilep- 
tic patients have their paroxysms come either in the night or early morn- 
ing. One important objection to the protracted use of the bromides, is 
their tendency to produce cutaneous eruptions, and sometimes to impair in 
some degree the nutritive functions. The tendency to induce cutaneous 
eruptions can in some instances be obviated for a considerable period of 
time, by adding a small proportion of the liquor potassii arsenitis to the 
formula that I have just mentioned; making the proportion such that an 
adult would get from two to four minims of the arsenical preparation in 
each dose. Guided by my own experience, I should say next in value to 
the combination that I have just given you, is valerianate of zinc in com- 
bination with such doses of the extract of stramonium, <or conium, as will 
be borne without producing noticeable dryness of the fauces, or dilatation 
of the pupils of the eyes. 



TREATMENT. 737 

Recently, bromine itself has been recommended, I think, by Dr. Ham- 
mond, as a remedy quite as efficient in ameliorating the epileptic condi- 
tion as anv of the bromides. For administration, one cubic centimeter 
(tl 5]-) of the bromine may be put into two hundred and sixty cubic 
centimeters (fl fviii) of water, with three or four grammes (31) of the 
bromide of potassium, to render the solution of the bromine in the water 
more perfect. Of this solution, four cubic centimeters (fl 3i) may be given 
further diluted with water, or sugar and water at the time of adminis- 
tration, three times a day. I have not had sufficient clinical experience 
with this remedy to express any opinion as to its value, although I should 
anticipate its effects would be very similar to that of the bromides, which 
have been so long and thoroughly tested. As I remarked before, so in 
closing this subject, I must remind you that a large part of your success 
in the management of cases of epilepsy will depend upon bringing them 
under treatment at an early period after the disease has commenced, 
paying close attention to a judicious regulation of the diet, exercise men- 
tal and physical, and to the careful maintenance of a healthy activity in all 
the important functions of the body. What I have thus stated in regard 
to the treatment applies to the disease as ordinarily presented to us for 
treatment, unconnected with any traumatic influence in producing it. 
As a matter of course, wherever cases of epilepsy are met with of a reflex 
character, and the primary seat of irritation can be determined, whether 
it involves the sentient nerves of the scalp, or any other part upon the 
exterior of the body, or a fracture or partial fracture of the bones of 
the cranium, or the existence of an irritable or diseased uterus, or irri- 
tating substances in the alimentary canal, in such cases I say, as a mat- 
ter of course, the leading object of treatment must be the removal of the 
primary seat of irritation, with whatever remedies are necessary for that 
purpose. Traumatic cases usually are to be remedied by surgical inter- 
ference, for the removal of spicule of bone, cicatrices and badly healed 
stumps after amputations, while diseases in the alimentary canal or 
in the viscera of the pelvis, male and female, or unusual sexual indul- 
gence, must be treated and controlled by the practitioner, by the use of 
such remedies as each individual case calls for. I apprehend that if we, 
as practitioners of medicine, should study the individual cases of epi- 
lepsy that cpme under our care, especially those that are presented in the 
early stage of their progress, more carefully in relation to the particular 
cause or causes, and make a more intelligent and thorough effort to re- 
move every point of irritation on the principles that I have laid down, a 
much larger number of cases of the disease would be permanently 
cured than have been heretofore. And yet I must admit, as I have already 
done, that after the disease has become of long duration or the habitual 
recurrence of paroxysms well established through a period of several 
years, it is really rare that any mode of treatment, however perseveringly 
followed, has succeeded in making a permanent cure or accomplish- 
ing more than a temporary amelioration of the condition of the patient. 
47 



738 CHOEEA. 



LECTUEE LXXIV. 



Chorea— Its Causes, Clinical History, Pathology, Diagnosis, Prognosis and Treatment. 

GENTLEMEN: The disease denominated chorea, sometimes popular- 
ly called St. Vitus Dance, is met with most frequently in children 
between the ages of five and fifteen years. It may occur earlier than 
five, and sometimes between fifteen and twenty-five. But probably eight 
out of ten of all the cases of chorea that occur, have their commencement 
within the ages first named. 

Causes. — A variety of causes have been alleged to be capable of in- 
ducing chorea, some holding the relation of predisposing, others that 
of exciting causes. Of the first, perhaps, an excitable temperament 
coupled with timidity of mind in children, constitute the most constant 
predisposing conditions. A very large majority of all the cases that 
come under my observation are in a class of children, embracing both 
males and females, of a rather amemic or delicate physical condition and 
a decidedly timid, diffident condition mentally. Yet, these conditions are 
not present in all cases of chorea, fori have met with some children of 
apparently sanguine temperament, hardy, well nourished and without any 
special mental trepidation or timidity. As a general rule, girls are more dis- 
posed to the disease than boys, and I have known a number of instances 
in which season of the j T ear appeared to exert an influence, the pa- 
tients having their attacks renewed in some instances every autumn, for 
two or three years in succession, apparently coincident with the occur- 
rence of cold, damp, and changeable weather. But in a large majority, 
it is not easy to trace any influence from the seasons of the year, or any 
particular diet or mode of life. Of the exciting causes, none are more 
prolific in developing the disease into activit}?- than fear, coupled with 
mental anxiety. Children going to school between the ages of seven and 
ten years, of a temperament such as I have indicated, find it a little diffi- 
cult to get their lessons to the satisfaction of their teachers, and are in 
consequence placed each day in a state of continual dread or apprehen- 
sion, which renders it still more difficult for them to make progress in their 
studies; and in a few weeks, or months at longest, of this regular daily men- 
tal trepidation and anxiety, coupled with fear of punishment, and perhaps 
aided by the jeers of their comrades in the same classes, they are discov- 
ered to be subject to certain muscular movements of the face and of the 
voluntary muscles of the hands and arms, which at first are not infre- 
quently mistaken for willful motions, and thus bring more scolding, 
more jeers, and add directly to the unhappy condition of the sufferer till 
the disease is fully developed. 

The same mental conditions may arise in families without the child 
having any connection with the school room. In fact, any train of cir- 
cumstances which tends to keep the child in a state of mental apprehen- 
sion, coupled with more or less fear, strongly acts as an exciting cause of 
this variety of nervous disease. Another class of cases has been plainly 
traced to the influence of cold and damp air or sudden checking of per- 
spiration. Indeed, not infrequently, the choreic movements have been 
associated with a moderate degree of rheumatic fever and soreness in 
different parts of the system, rendering it unmistakably a case of rheu- 
matic origin. One of the earliest well-marked cases of chorea that came 



SYMPTOMS. 739 

under my care after entering upon the practice of medicine, more than 
forty years since, was in a hardy, well-nourished boy of twelve or four- 
teen years of age, who, after working with other members of the family 
in the woods, chopping wood, on an early spring day, with the coat off, 
incautiously went home without putting his coat on and became some- 
what chilled. This was followed during the two succeeding days by a 
well-marked rheumatic fever, which abated somewhat during the follow- 
ing two days. But as the rheumatic fever diminished, severe choreic 
symptoms immediately followed, and proved quite persistent in its dura- 
tion. It is probable that the cases to which I have alluded as recurring 
at certain seasons of the year, particularly in spring and autumn, are 
usually of the class that might be styled rheumatic cases, or such as 
originate from imperfect eliminations through the skin and kidneys, and 
consequent retention of the products of tissue metamorphosis until they act 
upon certain portions of the nervous centers, producing choreic symptom?, 
instead of upon the muscular and fibrous tissues, which would constitute 
ordinary rheumatism. Other cases have been alleged to originate from 
drying up of suppurative sores, such as ulcers, and still more by the 
sudden and rapid disappearance of chronic cutaneous eruptions. Long 
standing eruptions, like chronic eczema of the scalp and other parts of 
the system, on suddenly disappearing, have been followed, though not 
very frequently, by choreic symptoms. Still other cases have been sup- 
posed to originate from irritation in the alimentary canal, either from in- 
testinal worms or indigestible food. It is proper to remark, however, that 
though I have observed a very large number of cases of chorea, I have no 
recollection of a single case that was connected either with intestinal 
worms or habitual indigestion; and I think not more than three or four 
in which there was any reliable evidence that the disease had originated 
from sudden drying up of ulcers, or the disappearance of cutaneous 
eruptions. But from impressions of cold and damp, I have met with a 
considerable number, while eight out of ten of all cases have been trace- 
able to mental impressions of a depressing character coupled with fear, or 
from sudden and severe fright. 

Clinical History. — In most cases the disease develops rather gradually, 
without any regular premonitory symptoms or warning, or any noticeable 
febrile stage. The first deviation from the natural condition noticed is 
usually the irregular movements of the muscles of one or both sides of the 
face. At first it may be merely an irregularly recurring spasmodic 
action or jerking of a particular muscle, either drawing the eyebrows up 
and forcing the eyelids together like a forcible wink, or more frequently, 
lifting one angle of the mouth. In a day or two after observing these 
slight spasmodic movements in some of the muscles of the face, the hand 
will be noticed to move irregularly, and sometimes when attempting to 
take hold of something it will be jerked suddenly in another direction. 
The feet may be moved in the same way. But if these symptoms have 
attracted attention or elicited inquiry, or if they are mistaken for volun- 
tary movements, and any chiding or reproof is administered, it usually 
directly increases the difficulty, rendering the spasmodic action much 
more frequent and violent than it was before. Some cases hardly go 
beyond the slight symptoms I have named. There is no disturbance of 
the pulse, no increase of temperature, indeed no particular development 
of other symptoms, but simply these slight and variable involuntary 
spasmodic movements of particular muscles, either of the face or extremi- 
ties, or of both. But in most instances where no remedies are inter- 
posed, the disease increases from day to day, arid in about one week after 



740 CHOEEA. 

the first noticeable irregular muscular movements, they will have ex- 
tended to nearly ail the voluntary muscles of the face, neck, and both 
upper and lower extremities; not that they will all be in motion at one 
time, but alternately and with entire irregularity; the muscles of the arm 
moving one second, and next a twitching in the muscles of the face or in the 
neck, shoulders or feet, rendering the various muscular movements entirely 
unsteady and without any successive order, and sometimes throwing the 
patient into the most grotesque and ludicrous attitudes. During the 
second week in a majority of ordinary cases, the disease reaches its climax 
of development, when the muscular movements become so severe and 
frequent that the patients can make no steady progress in walking; the 
legs are jerked in such an irregular manner as to render walking imprac- 
ticable, while the hands and arms are so suddenly and severely moved 
as to cause the dropping or throwing whatever may bein the hands, and 
rendering them incapable of even feeding themselves. Everything is 
thrown irregularly out of their hands, and they are sometimes not able to 
keep themselves in bed — the muscular movements of the trunk of the body 
as well as the extremities, throwing them from side to side until they will 
be dashed either against the walls along the bed, or out of the bed upon 
the floor. Where the disease becomes thus violent, there is usually con- 
siderable dilatation of the pupil of the eye, there is much difficulty in deglu- 
tition, and almost entire inability to talk, on account of the irregular 
movements affecting the muscles concerned, both in speech and deglutition. 
I have seen a few instances, where the spasmodic action during the par- 
oxysms was so violent, that it required the constant attention of one or two 
persons to keep the patients on the bed, and prevent them from suffering 
more or less personal injury by the uncontrollable and irregular muscular 
movements. It is very rare that the muscular movements involve the 
sphincters of the body, but in a few instances the patients have been un- 
able to control either their water or faeces. There is a decided parox- 
ysmal character to the irregular movements in almost all the cases of 
chorea. There are periods of a few minutes at a time in which the irreg- 
ular or spasmodic muscular movements will be very violent, extending 
over most of the voluntary muscular system, and then an interval of compar- 
ative quiet, sometimes lasting not more than two or three minutes, while 
at other times the intermissions between the paroxysms will be from 
fifteen to thirty minutes of almost entire repose. But in nearly all in- 
stances during sleep, the irregular muscular movements cease, and many 
of the choreic patients sleep as quietly as though they were in. perfect 
health. I have noticed only a few exceptions to this rule, in which some 
slight degree of spasmodic action continued during sleep. The natural 
tendency of the disease, as I have just remarked, is to reach the climax of 
its development during the latter part of the second week, continuing with 
but little change until toward the middle or latter part of the third week, 
when, in most cases, there begins to be a decline or an apparent tendency 
to spontaneous recovery between the end of the fourth and that of the 
sixth week. Mild cases have terminated earlier, and the severer ones 
sometimes have been protracted not only six weeks but as many months. 
As an ordinary rule, during the whole progress of the disease the patient 
retains a moderately fair appetite, the evacuations remain nearly regular, 
though sometimes inclined to costiveness, the urine usually of rather 
high specific gravity, and perhaps less in bulk than natural, although this 
varies with different cases. A few that have come under my observation 
made larger quantities of limpid urine than in health. Patients with this 
disease are usually also free from pain, except such as are of rheumatic 



PATHOLOGY. 741 

origin. These usually complain of more or less severe headache, and 
general muscular soreness or hyperesthesia; and, so far as I have ob- 
served, the urinary secretion is less than natural and of a deeper red color. 
During the first week, there is slight elevation of temperature and ac- 
celeration of pulse. But aside from this, I have noticed no general 
febrile phenomena, or any considerable pain connected with the disease. 
In the severer cases, where the paroxysms and violent muscular move- 
ments combined are such as I have described, the patient becomes 
exceedingly weary, apparently through voluntary efforts to lessen the 
uncontrollable movements. After the first two weeks there is noticeable 
usually some loss both in flesh and strength. The countenance is 
usually expressive of despondency, and the color of the lip evidently in- 
dicates impoverishment of the red corpuscles of the blood. 

While the descriptions I have given from the lighter class of cases to 
the more severe as they are usually met with, apply to those of most fre- 
quent occurrence, many show deviations that require mention. Among 
the more common of these deviations is the confinement of the disease to 
one side of the body, particularly one side of the face, one arm or one 
leg. In a few instances this has been well characterized, the muscles of 
one side being actively involved in the disease, while hardly an irregular 
movement can be detected upon the other. In other instances, the dis- 
ease is confined entirely to some limited portion of the voluntary muscles, 
such as those of the face alone. In other instances, the arms, the feet 
and legs, and in not less than three cases, I have found the patient ap- 
parently affected only in the muscles of the diaphragm and the anterior 
walls of the abdomen producing very marked and characteristic in- 
terference with the regularity of the respiratory movements, and of course 
with the regularity of the speech. One of these cases was a young wo- 
man of eighteen, who came from the interior of the State, and had been 
previously affected by the disease for some six months. It was limited 
entirely to the muscles of the trunk and diaphragm, cutting short her 
words at irregular intervals when conversing, forcing the breath suddenly 
out or stopping the respiratory act once or twice in its progress. In an- 
other case also, a young woman of twenty years, the disease was limited 
apparently entirely to the abdominal muscles and diaphragm, not affect- 
ing the muscles of the chest above the diaphragm, but involving the 
muscles of the abdominal walls in front to the pubis. But you must 
be prepared to meet with irregular choreic action in almost any of 
the muscles of the bod}" or extremities, either as affecting single mus- 
cles or associated groups, co-operating in certain movements. 

Pathology. — As uncomplicated cases of chorea rarely terminate fatally, 
but few opportunities have occurred for post-mortem examinations or for 
studying the structural changes that might be supposed to occur in the 
cerebro-spinal portions of the nervous system. But the disease, as ordi- 
narily met with, is so purely one of functional or temporary disturbance, 
tending toward recovery, that it is not probable that the closest scrutiny 
would detect any structural changes in the cerebral or cerebro-spinal 
structures, that could be considered as characteristic of this disease. The 
essential pathological condition connected with it, is undoubtedly one of 
a peculiar morbid excitability of certain tracts of nerve matter in the 
cerebro-spinal axis, extending perhaps more or less to the corpora-striata 
and optic thalami. The phenomena of the disease may originate in two 
ways, one by direct radiation of irregular nerve force upon voluntarv 
muscles, bringing them into irregular, involuntary action; in the other, 
not so much direct radiation of irregular nervous influence, as the loss of 



742 CHOREA. 

the power of the cerebral hemispheres to control and direct voluntary 
movements. The latter is the case in most instances, where the disease 
has originated from mental influences, acting upon a timid nervous tem- 
perament, while the former, the direct establishment of irritative influ- 
ence, is the predominating pathological condition in those cases which 
originate from exposure to cold, wet, and other causes, which would favor 
the development of the rheumatic irritation, and from the drying up 
of ulcers, or the sudden disappearance of cutaneous eruptions. There is 
no evidence that any, except well marked rheumatic cases, are accompa- 
nied by any distinct hyperaemia or increase of blood in the nervous cen- 
ters. On the contrary, the absence of fever and local heat in the head, 
the predominance of paleness, anaemia and dilatation of the pupils, as 
the disease becomes more severe, all indicate rather an anaemic condition 
of nerve centers, than anything meriting the name of hyperaemia or full- 
ness. But in some of those cases which originate from causes tending to 
suppress either natural or unnatural secretions, there are often indications 
both of febrile disturbance, and of hyperaemia of the central portion of the 
nervous system. 

Diagnosis. — The symptoms of chorea after they have been once ob- 
served are so characteristic and different from almost every other variety 
of irregular muscular action, that there is very little danger of mistakes 
in diagnosis. The action of the muscles in an irregular or entirely in- 
coherent manner, at no time obliterating the patient's consciousness, or 
wholly obstructing the respiration, so as to produce the ordinary phe- 
nomena of convulsions, the recurrence of the movements every few 
minutes, all tend to distinguish it from any form of general convulsion. 
The long relaxation of the muscles in the intervals between the. short, 
spasmodic jerking, separate it at once from all forms of tetanic rigidity, 
or cerebral disease accompanied by ordinary paralysis with a rigidity of 
muscles; and on the other hand, it only requires the observation of a 
single case to see a broad difference between the muscular movements oc- 
curring irregularly, first in one place and then in another, with intervals 
of rest after each paroxysm, and the steady tremulous shaking of paraly- 
sis agitans. There is indeed no other form of nervous affection that 
exhibits phenomena which, in their aggregate, have any near resemblance 
to those of chorea. 

Prognosis. — As a general rule, the prognosis in chorea is favorable. 
Although I have met with a large number of cases of this disease, and 
at almost all stages of their ordinary progress, and in all grades of 
severity, I have known no cases which terminated fatally, and I think 
only three that did not recover. These three were in adults, all of whom be- 
fore coming under my observation, had suffered from the disease for 
periods varying from fitteen to twenty years, and, at the time, had evi- 
dently become complicated with symptoms indicating structural change 
in certain parts of the spinal cord and medulla oblongata somewhat 
similar to that in progressive locomotor ataxia. Cases that are brought 
under observation and are subject to proper regulations in the early 
stage, will always end in recovery, and usually within a period of 
from three to six weeks. 

Treatment. — The first object to be accomplished in the treatment of 
chorea is, so far as possible, to remove the further operation of all such 
influences as might have constituted exciting causes, or more properly, 
of such influences as might have contributed to the development of the 
disease. This is particularly necessary in all such cases as have origi- 
nated mainly from mental influences. The child, if attending school, 



TREATMENT. 743 

should be at once removed, if for no other reason than from the fact that 
it is impossible for a child to attend school, laboring under this disease, 
and not attract the attention of the other scholars. If the teacher him- 
self suspects the nature of the disease and treats the child with admitted 
judiciousness, the attention of other children will be constantly attracted 
to the awkward and grotesque movements, and their observation and con- 
versation will most certainly tend to perpetuate the disease in this class of 
patients. Another objection is, that there are liable to be other children 
of temperaments favorable for developing the same disease, and the pres- 
ence ot" one case very generally creates more or less disposition to imitate 
it on the part of others, which sometimes actually develops the disease in 
the imitators, and thereby increases the number of cases among the 
children thus associated. 

After removing the child from contact with other children as far as is 
practicable, both in the school and in the neighborhood, and directing that 
it shall be provided with such influences, proportioned to its age, as will 
divert its attention and promote its cheerfulness, secure for it some 
exercise by riding and outside exposure, always in company with some 
cheerful attendant, who will be ready to pass every awkward and irregular 
movement by unnoticed. And the parents or immediate attendants 
should be strictly enjoined to pass all irregular movements, blunders, or 
accidents that the child may make with as little notice as .is compatible 
with the safety of the patient, and that all mistakes or accidents resulting 
from spasmodic movements, either in attempting to feed themselves or 
to hold anything in their hands, should be overlooked or excused with a 
word of encouragement and cheerfulness. I speak of the necessity of 
thus directing the management of patients suffering from chorea produced 
by mental influences, from having frequently observed that in all the 
working classes of people, and indeed, more or less among all classes, 
there is great proneness to a directly opposite mode of management. 
The anxiety of the mother causes her to pay attention to every awkward 
movement, and in the earlier stage of the disease, not understanding its 
nature, until it has been aggravated to its highest degree of development 
by her chiding and upbraiding or liberally scolding for almost every 
awkward movement the child may make. For the more the patient is 
scolded, the more irregular and excited its movements become. Conse- 
quently, one of the most important items in the management is to place 
the patient in a comfortable condition of air and warmth, a plain un- 
stimulating, but nutritious diet, and in the immediate care of judicious 
and cheerful companions and nurses. Indeed, this alone will serve to 
restore the larger proportion of this class to health in from three to four 
weeks. I have said that the diet should be plain, unstimulating, but 
sufficientlv nutritious and easily digested. The patient needs a fair 
amount of nutriment, yet the digestive organs should not be overtaxed, 
and especially with indigestible food. Tea and coffee should be. either 
prohibited or used sparingly; and no other so-called stimulating drinks 
should be allowed, either fermented or distilled. Attention should be 
given to the condition of the evacuations, both from the bowels and the- 
renal organs, sufficient to see that the bowels are moved naturally and 
regularly, but without the debilitating effects of physic, and that the 
urinary secretion is sufficiently abundant to fully separate the elements of 
the urine from the blood. In most instances there is very little variation 
from natural in either the digestive organs or renal function. In those 
cases which have arisen mostly from mental influences, the medical treat- 
ment should have two objects in view. One mildly tonic, the other anti- 



744 CHOREA. 

spasmodic or quieting to irregular nervous action. The particular 
remedies which have appeared to exert the most reliable control over the 
progress of the disease and lead to the earliest recovery, have been 
valerianate of zinc, and liquor potassii arsenitis or Fowler's solution. To 
patients between the ages of five and ten years, I have usually given 
thirteen centigrammes (gr. ii) of the valerianate of zinc, usually in the 
form of a gelatine-coated pill, for convenience of administration, before 
each meal and at bed-time, and from three to five minims of the liquor 
pot-issii arsenitis in 15 c.c, or a tablespoonful of water just after each regular 
meal. For the last twenty years I have met with but very few cases of the 
variety of chorea to which I am now alluding, that have not yielded to this 
treatment, and become convalescent in from two to three weeks. In a 
few instances I have had to continue it four weeks, and in a still smaller 
number of cases I have found the arsenical preparation to produce disturb- 
ance of the functions of the stomach, constituting loss of appetite, and some- 
times griping and a little looseness of the bowels, and have been obliged to 
discontinue it on that account. I think, perhaps, in two or three cases it has 
interfered with the action of the kidneys, and led, in less than a week 
from the time it was commenced, to an cedematous condition and puffiness 
of the loose tissue under the eyelids in the morning, and more or less of 
oedema about the tops of the feet and ankles during the afternoon 
and evening. Of course in all such cases it was immediately discon- 
tinued. When the arsenical preparation in any respect disagrees (and 
you should never administer it without taking subsequent care to note 
its effects) the patients frequently will recover in a reasonable time under 
the influence of valerianate of zinc alone. If they are unusually rest- 
less at night, one moderately full dose of valerianate of ammonium given 
at bed-time, will both secure rest during night and contribute to steady 
the irregular muscular action during the following day. A combination 
of the bromide of ammonium and hydrate of chloral, in doses suited to 
the age of the patient, given morning and evening, has sometimes acted 
very favorably in removing the irregular muscular movements, and at the 
same time promoting sleep at night. In those cases which have come under 
my observation of the most severe character, in which the paroxysms had 
rendered the patient wholly unable to walk or talk or even to swallow 
without more or less difficulty, requiring one or two attendants constantly 
to keep them in bed, I have found it of great advantage to administer 
once or twice in the day, say morning and evening, a warm douche upon 
the occipital region and back of the neck. The mode of administration 
has been to bring the patient's head and neck out from the front edge of 
the bed, horizontally over a tub, with the face downward, and from a 
pitcher holding one or two quarts of warm water, not hot, but simply 
warm as is comfortable, and, holding the pitcher from one to two feet 
above the head, pour a continual stream upon the occipital region of the 
head and neck. The position is such that the water runs directly off into 
the tub, and when from one to three quarts have been thus poured in a 
steady stream, the water is wiped quickly off and the patient laid 
back upon the bed to rest. In most instances the douche is followed by 
one or two hours of continuous rest, with but little muscular agitation. 
And a repetition of it once or twice a day during the week that the disease 
is at its climax, or while it is approaching its climax, has seldom failed to 
greatly facilitate a cure. When patients are very anasmic they may be 
benefited by giving more or less of those preparations which are regarded 
as calculated to promote nutrition, and especially to favor the formation 
of red corpuscles of blood. With such the arsenical preparations may be 



TREATMENT. 745 

given in direct conjunction with suitable doses of the lacto-phosphate of lime 
compound syrup of the hypo-phosphites, or with the compound tincture 
of oinchona, which perhaps constitute the best of the class of nutrient 
tonics that we can use in such cases. I do not mention the preparations 
of iron, for the reason that in a majority of instances in which I have tried 
them they have seemed to me either to produce headache after a few days 
or to actually increase the irregular muscular movements. This has led 
me to think that iron is not well tolerated in that peculiar condition of 
the nervous system giving rise to choreic movements. While the treat- 
ment that I have now mentioned is that which ray experience has shown 
most successful in the treatment of the common class of cases of chorea, 
those arising from sudden exposure to cold, and that are plainly associated 
with more or less of a rheumatic grade of irritation, will not so readily 
yield to the same remedies. But they require to be carefully discrimi- 
nated and early subjected to the influence of a different class of remedial 
agents. Such cases, at their beginning, while there is some feverishness, 
general muscular soreness, some degree of headache, with slight accelera- 
tion of pulse, will perhaps be more promptly benefited by a solution of sali- 
cylate of sodium in connection with tincture of cimicifuga racemosa and 
gelsemium, than by any other remedies. A combination of these three 
medicines in such proportion as to adjust the dose of each to the age of the 
patient, aiming to get a fair but not exaggerated influence, and given once 
in from four to six hours, will usually produce decidedly ameliorating effects 
within the first five or six days, and sometimes entire relief of all the symp- 
toms. A case to which I have already alluded that occurred during a 
very early period of my practice, in a boy, who, in returning from his 
work was suddenly chilled, and soon after attacked with very severe 
chorea, was entirely relieved and convalescence established by the use of 
the warm douche applied thoroughly twice a day for the first three days, 
once a day afterwards, and the internal use of a combination of the 
tincture of cimicifuga, wine of colchicum root and tincture of stramonium. 
Cimicifuga has been recommended by many in the treatment of chorea, 
but I am satisfied that its efficacy is restricted almost entirely to the 
rheumatic class of cases. And in those, either alone, or still better in con- 
junction with salicylate of sodium and moderate doses of stramonium, it 
will certainly produce very satisfactory results. Colchicum is particularlv 
valuable as an addition to the treatment in such cases as are accompanied 
by more or less constipation and checking of the urinary secretion. It 
may be pushed until it produces some laxative effect, but should not be 
carried so far as to produce hyper-catharsis or intestinal irritation. Many 
other remedies have been suggested and used in the treatment of cases of 
chorea, but if you keep in mind the fact that the disease is only a 
functional disturbance, consisting mostly of a morbid state of excitabilitv 
coupled with a tendency to anaemia, impoverishment of blood and mental 
depression, and that your remedies are to be adjusted for the relief of 
these, you will seldom be at a loss to find in the materia medica sufficient 
material to fulfill the indications presented by the disease. You should 
remember that the earlier cases are brought under proper domestic regu- 
lations, such as will remove them from all causes calculated to aggravate 
the disease, the better will be the prospect of a speedy and permanent 
cure. Only one additional word in relation to preventing a recurrence of 
the disease. In a few instances, I have found relapses to occur by allow- 
ing children who had recovered from attacks to resume their school duties 
early, and thereby expose them to the same influences that had contributed 
to develop the disease at first. Care should be exercised in this regard. 



740 CATALEPSY. 

and the children either not allowed to return to school till such time as 
recovery has been well established, or what is better by far, the children 
should be placed under such teachers and in schools of such select, limited 
numbers, as will enable the patients to enjoy a reasonably judicious men- 
tal training and development, with but little liability to exposure to 
influences that would provoke a return of the disease. 



LECTURE LXXV. 



Catalepsy and Convulsions— Their Clinical History, Pathological Relations and Remedial 
Management. 

GENTLEMEN: The next subject to which I will direct your attention 
is called catalepsy. It is one of the most infrequent of the functional 
disturbances of the nervous system possessing the characteristics of a dis- 
tinct disease. Although occurring very rarel} T , it has been recognized and 
described from a remote period of medical history. It occurs most fre- 
quently during the period of youth and the early part of adult life, and 
seems in nearly the same ratio of frequency in both sexes. The causes 
of the disease are not well ascertained, although particular cases have 
been found to originate from malarious influences, and to exhibit distinct 
periodicity in the recurrence of the paroxysms; others have been apparent- 
ly developed by strictly mental influences, such as strong mental emotions; 
and in others no direct exciting cause has been traced. An excitable, or 
what is recognized as a nervous temperament, coupled with more or less 
anaemia, or impoverishment of blood, and also such mental conditions as 
cause a predominance of despondency or melancholia are regarded as 
predisposing causes. This disease, though presenting symptoms during 
its more positive manifestations or paroxysms, somewhat uniform and 
characteristic, is evidently closely related in some instances to hysteria, 
in others to particular forms of insanity, while in other and very rare in- 
stances, it seems to depend upon the action of malaria on a peculiar prior 
condition of the nervous system. And hence the cases met with in prac- 
tice may be grouped into three classes: the malarious, hysterical and 
psychical, or such as are associated more or less with mental derangements. 
Symptoms. — Most cases of catalepsy occur in paroxysms, entirely irreg- 
ular as to the time of their recurrence, and generally commence sud- 
denly, with no well-marked premonitory or prodromic symptoms. In some 
of the cases, however, a marked development of symptoms is preceded 
for one, two or three days by unusual taciturnity of mind, indisposition t 
to converse, with insomnia, or disturbed sleep at night. In other cases 
the paroxysms have been preceded by unusual hilarity, nervous excitabil- 
ity, and a rapid passage of emotions from one extreme to another. But 
in the larger majority of cases the development of catalepsy occurs sud- 
denly, and consists mainly in a suspension of cerebral consciousness 
coupled with general rigidity of the voluntary muscular s} T stem, leaving 
the patient in a condition apparently oblivious to surrounding objects or 
conditions, manifesting no apparent consciousness either to the touch or 
to the infliction of external injuries, or to the observation of conversations 
that may take place in their presence. But the muscular rigidity is of 



SYMPTOMS. 747 

such a character that the flexors and extensors are usually evenly bal- 
anced, leaving the patient directly in the attitude in which the attack 
supervened, whether standing, sitting or recumbent, as though the mus- 
cular system had suddenly assumed an entire fixed condition, offering a 
certain degree of resistance to all attempts to move the patient from the 
attitude in which the attack supervened. Muscular rigidity, however, will 
usually yield gradually to moderate force, allowing the limb to be raised, 
lowered, or moved in any direction, not suddenly by muscular action, but 
as though it were the yielding of an inelastic body to superior force, and 
the part remains in whatever position it may be placed by such force. 
This maintaining its position, however, in any particular attitude in which 
a part may be placed is not permanent. For instance, if the arm or limb 
be raised or extended and left unsupported, while it retains its position 
for a time, usually after ten to twenty or thirty minutes it slowly, without 
tremor or vacillation, yields to the force of gravity until it reaches a point 
of support. But for a brief time the limbs or body may be molded into 
almost any shape, and they retain for a time the position in which they may 
be placed. In two cases of a strongly marked cataleptic character occurring 
under my observation in the Mercy Hospital, at different periods of time, 
the rigidity of the muscular system was well marked, and the suspension 
of consciousness, or incapability of receiving external impressions, was 
such that no manifestations were obtained by the most varied efforts and 
experiments; and the house physician at that time, although expert in 
devising measures for testing the reality of the apparent suspension of 
consciousness, as well as fixedness of the musuclar condition, tried many 
expedients, including electricity, without producing the slightest apparent 
effect. 

In these cases the paroxysm continued in one five or six days, and in 
the other between two and three weeks. In the great majority of cases, 
however, the paroxysms of unconsciousness and muscular rigidity are of 
shorter duration. In some they remain only for a few minutes, in others 
one to three hours and from that up, as I have intimated, to as many 
weeks. Of course, in those cases where the suspension of consciousness and 
rigidity remain more than a single day, there is danger of progressive 
exhaustion from inability to nourish the patient without resorting to more 
or less forcible means for that purpose. In almost all cases the paroxysms 
of this unconsciousness and rigidity cease almost as suddenly as they 
supervene. The patients often appear as though they had just awakened 
out of a profound sleep, and not infrequently yawn once or twice, look 
about them as though in a strange place, and present all the expressions 
and movements of those who had recovered wakefulness directly from a 
protracted state of oblivious sleep. They usually resume their move- 
ments, however slowly, and exhibit a considerable degree of feebleness 
during the first few hours, and sometimes for one or two days, if the 
paroxysm has been protracted. There are various degrees of severity in 
the paroxysms of catalepsy. Some of the cases that have been termed 
catalepsy, and (.escribed as such, might better have been termed instances 
of simple trance, being temporary suspensions of consciousness, with 
little or no true muscular rigidity. While in the cataleptic paroxysms 
the muscular rigidity is restricted essentially to the nerves and muscles of 
voluntary motion; there is at the same time a diminished action in some 
of the involuntary movements. Respiration, for instance, is usually per- 
formed much less efficiently than in the natural condition. In those cases 
that have come under my own observation the ordinary respiratory move- 
ments in the paroxysms have been so inefficient that it required close 



748 DIAGNOSIS. 

watching to observe any expansion and contraction of the chest, or the 
ordinary motions of inspiration and expiration. While this was the case, 
however, with the ordinary respirations, every few minutes this inefficiency 
was compensated for by a single, slow, long inspiration, resembling a sigh. 
And this sigh or extra respiratory movement constituted the strongest in- 
dication of the patient's capacity to move that was observable during the 
paroxysm. The face is usually pale, the extremities cool, pulse soft and 
easily compressed, but nearly of the natural frequency. In those cases 
which are dependent for a direct exciting cause upon malaria, the ter- 
mination of the paroxysm is usually accompanied by temporary sweating, 
and sometimes it is begun by a noticeable coldness and blueness of the 
lips and nails, as though there was a slight semblance of a chill. 

Pathology. — Catalepsy being a very rare disease, and the cases that 
have occurred rarely terminating fatally unless when associated with cere- 
bral disease, or .some of the forms of insanity, there have thus far been dis- 
covered no characteristic appreciable lesions of the nervous centers, on 
which the phenomena could be said to depend. And it is probable that 
uncomplicated catalepsy is purely a functional disturbance of the nervous 
centers, consisting in the temporary loss of cerebral recognition, or mental 
perception of outward impressions, with coincident radiation of sufficient 
nervous influence through the nerves connected with the voluntary mus- 
cular system to hold that system in a state of rigidity, in equipoise, or 
fixedness. Some writers have suggested that contraction of the muscular 
fibers was the natural condition of that structure, and style rigidity as the 
natural muscular tonus, and endeavor to explain the general, equal rigid- 
ity of the whole voluntary muscular system, on the supposition that the 
nervous force commanding muscular movements and muscular action is 
like that of the cerebral function, suspended. And, instead of the nerv- 
ous impression commanding muscular rigidity, it is simply a withdrawal 
or temporary suspension of all nervous influence, allowing the muscular 
structures to resume their supposed natural tonus, in a fixed or rigid state. 
The difficulty, however, with this theory is, that the fundamental proposi- 
tion of the existence of a natural muscular tonus has no adequate proof. 
It must be confessed that it is difficult in the present state of our knowl- 
edge, to furnish a satisfactory explanation of all the phenomena or 
symptoms, which constitute an attack of catalepsy. That it is afunctional 
disturbance, not involving necessarily structural changes, is quite evident 
from the readiness with which paroxysms come on, and the equal readiness 
with which they pass off, and the almost universal tendency to recovery, 
or at least to avoid fatal consequences. 

Diagnosis. — The simple description of the symptoms which I have given 
you furnishes the best means for diagnosis. There is no other form of 
disease that gives the same assemblage of symptoms, namely, the coinci- 
dence of suspended cerebral recognition of. impressions from without, 
with a steadily balanced and continuous state of rigidity of the voluntary 
muscular system. Tetanus, hysteria, and all. the various forms of irreg- 
ular muscular action, are more particularly paroxysmal, and are associated 
with other coincident phenomena, entirely different from that of cat- 
alepsy. In simple trance, and in the various conditions of peculiar mental 
emotion that are sometimes observed, there is lacking the muscular tonus, 
or rigidity, which belongs to the cataleptic state. 

Prognosis. — As I have already stated, the prognosis having reference 
to the amount of danger to the life of the patient, may be said to be favor- 
able in all cases that are not complicated with mental diseases, or some 
form of insanity; but, so far as relates to the prospect of recovery in the 



TREATMENT. 749 

sense of being exempt from liability to recurrence of paroxysms from time 
to time, the prognosis is not so favorable; there being a strong tendency 
in the disease to an irregular recurrence of attacks, in some at long inter- 
vals and in others more frequently, especially when the patient has passed 
the period of puberty. If it is certain that the paroxysms depend for their 
exciting cause upon malarious influence, the prognosis is decidedly favor- 
able. Such cases are usually permanently cured, first, by antiperiodics to 
interrupt the paroxysms, and subsequently by proper attention to the im- 
provement of the general health and tone of the nervous system. When 
they occur at, or before the period of puberty, proper attention to their 
physical and mental training continued for one, two or three years will 
usually destroy their liability to recurrence of attacks and secure for them 
a permanent recovery. 

Treatment. — The treatment evidently divides itself into two parts: 
that which is required during the paroxysm, or the continuance of the at- 
tack, and that which is necessary for preventing its recurrence. In cases 
where the patient has already passed through one or more paroxysms, and 
it has thus been ascertained that they are of temporary duration it is not 
desirable to institute decided and active measures of treatment till the 
paroxysm has passed by. But if the paroxysm is more lasting, extending 
any period beyond twenty-four hours, some measures may be resorted 
to with the hope of shortening its duration, and thus restoring the patient's 
ability to take nourishment before material exhaustion has taken place. 
Among the expedients that are perhaps most likely to terminate the 
paroxysm, are sudden dashing of cold water upon the face and naked 
chest, which sometimes will bring a sudden inspiratory effort coupled with 
an immediate return of consciousness and ending of the paroxysm. Mod- 
erate electric shocks will sometimes succeed in producing some effect. 
Both, however, have frequently been found ineffectual, and all other simi- 
lar expedients. Sometimes the administration of enemas, containing such 
remedies as assafcetida, valerian, camphor, or almost any of this class of 
antispasmodics and stimulants, have been found sufficient to arouse the 
patient, and end the paroxysm. In the two cases to which I have alluded 
in the hospital none of these expedients had any effect. In one of them, 
milk or any item of liquid food, when the underjaw could be depressed 
sufficiently by a moderate, steady pressure to allow nourishment to be 
placed far back upon the tongue, would be swallowed slowly, but some- 
times with difficulty and some danger of choking. But it was tedious 
and difficult to administer enough to adequately sustain the patient. 
Enemas of milk and beef tea were generally retained when given in 
quantities not exceeding 90 or 120 cubic centimeters (fi. ^iii to ?iv) at a 
time, and constituted the principal dependence for nourishment. In the 
patient in whom the paroxysm continued beyond the second week and 
symptoms of exhaustion became strongly marked notwithstanding the 
efforts to nourish him by enemas, I found great difficulty in getting his 
mouth sufficiently open to place anything upon the back part of the 
tongue. It appeared to me that it was one of the cases closely allied to 
insanity as it had been preceded for a considerable time by melancholia. 
The difficulty of administering nourishment by the mouth appeared to be 
increased by some voluntary resistance added to the rigidity constantly 
existing. But the necessity for more nourishment became so urgent that 
the nurse and house physician proposed, at one of my visits, that 
we forcibly introduce the stomach tube and pour nourishment into the 
stomach. Being satisfied from what I could learn of the history of the 
patient that there had been some indication of mental derangement, it 



750 CATALEPSY. 

occurred to me that possibly a little strategy might be valuable, and 
after talking freely by the bedside about the necessity of resorting to forci- 
ble administration of nourishment in the manner I have just suggested, 
I made the remark, that if there was no change by the next day we would 
resort to it, but would postpone it that long. As we stepped beyond the 
hearing of the patient, I instructed the nurse to do as he had been in the 
habit of d >ing every day, i. e., bring the patient nourishment, make some 
little effort to feed him, but without much persistence, and then, as if 
doing it carelessly, or by accident, in the evening leave a bowl of milk 
upon a stand directly at the bedside of the patient, where it could be 
easily reached, if the patient were disposed to reach it during the night. 
This was done, and the next morning the milk was gone, with reasonable 
certainty that no one else had meddled with it but the patient. For three 
or four successive evenings the milk was left in a similar way, and uni- 
formly disappeared before morning, at the end of which time, the patient 
was found early in the morning out of bed, standing motionless as a 
statue, in undress, gazing at a picture upon .the wall. He was persuaded 
with a little assistance, again to resume his bed, and from that time on 
slowly recovered his perceptions, and with apparent reluctance took 
nourishment, and became better from day to day, and in about four weeks 
more had regained a fair degree of strength. And although decidedly in- 
disposed to talk much, he left the hospital apparently sane, and in a pretty 
good physical condition. The treatment which is required in the inter- 
vals between the paroxysms of a case of catalepsy must be varied to suit 
each individual case. Where the patient is under malarious influence, the 
prompt use of efficient, though not exaggerated doses of antiperiodics 
mild tonics, easily digestible food, passive exercise in the open air by 
riding, and avoiding direct physical fatigue, constitute the means which will 
usually speedily restore such patients to entire health. In those instances 
that prove to be connected with mental disease, there is almost always 
more or less structural change in some portion of the brain, and usually 
all treatment proves only palliative, so far as restoring the patient's health, 
and the cerebral disease goes on to its usually fatal result, whether the cat- 
aleptic paroxysms continue to recur or not. The treatment of such cases 
must be governed entirely by the indications afforded by the accompanying 
form of cerebral or cerebro-spinal disease. There are cases, however, that 
are neither influenced by malaria, nor by organic structural changes, but 
are more allied to hysteria, in which the two leading objects of the 
treatment in the intervals, will be to diminish the morbid excitability of 
the nervous system, on the one hand; and to support strength and func- 
tional regularity, especially in reference to digestion, assimilation, nutri- 
tion and regularity of excretory actions, on the other, as the best and 
surest means of preventing a recurrence of the cataleptic paroxysms. 
Good air, moderate outdoor exercise in proportion to the strength of the 
patient, encouraging and cheerful mental influences where it is practica- 
ble, and change from the interior to the sea-shore in the summer, and 
especially, in all cases, such measures as tend to give cheerfulness and 
mental courage, and light but varied occupations, will be found of much 
benefit. 

Convulsions. — Although there is no disease of the nervous system 
which can be properly designated convulsive, or justify the use of the 
word convulsion, to indicate any particular disease, yet a few words in 
regard to convulsions in the abstract may not be unprofitable. General, 
irregular muscular contractions, or what are termed clonic spasms, or fits, 
are simply symptoms of some prior or coincident pathological condition, 



CONVULSIONS. 751 

and not a distinct disease. The convulsive affections that we meet with 
may be arranged under various heads, according to the pathological con- 
ditions, or diseases on which they depend. Most writers speak of infan- 
tile convulsions, hysterical, puerperal, renal, and epileptiform convulsions. 
The latter I have already sufficiently considered, in the remarks upon 
epilepsy. The renal convulsions, by which are meant convulsions depend- 
ent upon retention of the elements of urine acting upon the nervous 
ce iters, I have also sufficiently considered in connection with inflamma- 
tory diseases of the kidneys. Puerperal convulsions, many cases of which 
are closely allied to the renal, are fully considered in works upon gyne- 
cology and obstetrics, and are not considered as within the domain of 
practical medicine. The hysterical, will be more appropriate under the 
head of hysteria, to which I shall soon direct your attention. 

This leaves me only what has been styled infantile convulsions for 
brief consideration at the present time. And even a large part of the 
cases of infantile convulsions may be traced to one of the preceding 
classes. Not a few of the convulsions that occur in infancy, although 
not often recognized as holding that relation, are nevertheless strictly 
epileptic, recurring at intervals of one, two, three, or six months, some- 
times in single paroxysms, sometimes in two, three, or four paroxysms, in 
quick succession. These patients speedily recover, and go on again 
without any apparent cerebral lesion, or associate morbid condition. 
Consequently parents and sometimes the physician come to regard them 
as dependent on some temporary cause. If it is before the teeth have 
all come through, most of them will be referred to the supposed progress 
of some one or more teeth that are crowding upon the gums. If there is 
no opportunity to render this cause available, worms will be called into 
requisition as irritating the alimentary canal; yet I have never seen a 
case in which worms were procured by any quantity of worm medicines 
administered to this class of subjects. The truth is, however, that the 
cases to which I now allude, and that begin often as early as six months 
of age, and make their appearance more or less approximating to regu- 
larity once in three, four, or six months, are true epileptiform convulsions 
in infancy and childhood. Sometimes, although disappearing from the 
third or fourth years of age up to that of puberty, and re-appearing at pu- 
berty, the spasms then are for the first time recognized as epileptiform, 
and in many of the cases without any recollection of the paroxysms 
suffered in infancy. Such cases require the same remedies, adminis- 
tered under the same general principles of treatment that I have already 
given you as applicable to cases of epilepsy generally. And it is desirable 
that you pay close attention to every case of convulsions that occurs in 
young children, and disappears leaving no marked symptoms of serious 
cerebral lesion, and recurs again without adequate cause at some stated 
period of time; because, if recognized, and put upon such regimen and 
remedies as are known to produce the most effect in controlling epileptic 
disease, there is the best chance of effecting a permanent cure. There 
are also some cases in childhood, or even in infancy, in which convulsions 
depend upon inadequate elimination of the urinary secretion, and are 
true ursemic convulsions. 

It is frequently the case that convulsions have occurred for the first 
time in infants and young children during the period of convalescence 
from attacks of the eruptive fevers. Aside, however, from these cases, we 
meet with convulsive attacks in children of more or less severity, that can 
not be referred to any other than temporary causes acting upon a peculiar 
susceptibility of the cerebro-spinal nervous centers, more especially that 



752 CONVULSIONS. 

part of the cerebrospinal axis which is related to the voluntary muscular 
system, and the voluntary nerves of sensation. There are many infants 
and young children in whom there is undue excitability in this portion of 
the nervous apparatus, and trifling causes of an irritative or exciting 
character are liable to bring them into paroxysms of general convulsive 
movements. Children born of scrofulous or tuberculous parents, are per- 
haps more liable to have this peculiar excess of excitability in the nervous 
system than any others. Next to these are children born of parents who 
are themselves subject to hysteria or epilepsy, and have themselves in- 
herited what might be called a hysterical temperament. Those born of 
scrofulous or tuberculous parents in addition to the morbid excitability 
favoring the ready development of convulsive paroxysms, present also a 
strong tendency to more or less permanent hyperemia of the membranes 
and surface of the brain, which, if not carefully and persistently counter- 
acted, is liable to terminate in effusion, constituting a form of hydrocepha- 
lus, which will terminate fatally at some future period, either with or 
without the development of miliary tubercles in the membranes and surface 
of the brain. Those infants and young children that possess what I have 
styled as the hysterical excitability of the nervous system, either by inherit- 
ance or otherwise, are liable to be attacked with general convulsions when- 
ever any temporary causes are brought to bear sufficient to produce fever or 
increase of temperature and rapidity of circulation, such as the superven- 
tion of scarlatina, variola, or even more transient fevers, and on the other 
hand by the occurrence of any causes that act slowly but persistently on 
the peripheral extremities of the sentient nerves, whether spinal or 
ganglionic. It is in this class of young children that we every now and 
then find a paroxysm of violent general convulsions on the first develop- 
ment of the febrile symptoms, which usher in any one of the eruptive or 
general fevers. It is in the same class that temporary derangements 
of digestion from taking indigestible food, or the presence of worms or any 
species of irritative influence in the alimentary canal, acting upon the 
sentient nerves of organic life, produce convulsions. 

In the same class of children after they have passed the period of in- 
fancy, between three and five or six years of age, strong mental excite- 
ment, constant fear, injudicious and violent chastisement, will not in- 
frequently cause the development of convulsive paroxysms. Yet, in all 
this class of cases the convulsions are usually of brief duration, and not 
often repeated, or more than one paroxysm at a time. The patient usually 
recovers quickly and fully from the attack, thus distinguishing them from 
cases that depend upon cerebral disease, in which, when the convulsive 
paroxysm passes away, the patient is still left with moderate fever, and 
other symptoms of cerebral disturbance. It is not necessary to absorb 
your time with a description of what is usually called a convulsion or fit. 
The sudden suspension of consciousness, the characteristic irregular mo- 
tions of the eyeball, jerking of the muscles of the face, choking in the neck 
as if strangulating, are followed in a few seconds by general clonic 
spasms. The suspension of respiratory movements, causes the lips and 
face to become turgid with dark venous blood, finally ending in a 
gradual relaxation, until in a few seconds more the muscular rigidity is 
gone and the patient lies as if in a sleep, although breathing stertorously 
from the accumulation of phlegm that has taken place in the mouth and 
fauces during the time of the general convulsive movements. So strik- 
ing is this assemblage of symptoms that even non-professional persons at 
once style them a convulsion or " fit." The patient left alone lies as if in 
a sleep for a period varying from a few minutes to half or three quarters 



SYMPTOMS. 753 

of an hour, but on awakening, speedily recovers from <tll bad symptoms, 
unless, after the blood has again become well oxygenized and decarbon- 
ized, a second paroxysm should supervene. These phenomena are so fa- 
miliar and characteristic, as constituting a convulsive paroxysm, that it is 
unnecessary to describe their variations or their degrees of severity. As 
you will infer from what has already been stated, the essential patholog- 
ical condition is the morbid excitability, or susceptibility of the cerebro- 
spinal nervous centers, acted upon by some temporary exciting cause. The 
treatment, as in cases of catalepsy, divides itself into that which is neces- 
sary during the paroxysms, and that which is required after the paroxysm 
has passed by, to prevent its recurrence and restore the patient more fully 
to a normal or healthy condition. 

Most convulsions are so temporary in their duration, so completely and 
necessarily self-limited, that the treatment really, during the convulsion, 
is of no value. But the terror of parents, nurses, and attendants, at the 
primary appearance of the convulsive movement is such, that the most rapid 
and instantaneous efforts are made to apply remedies with the expecta- 
tion of relieving the patient. Of course, with most of the people, what- 
ever remedies happen to be in use at the time the paroxysm subsides gets 
the credit of having stopped the "fit," when in ninety-nine cases in a 
hundred it had no influence whatever. In fact, a general convulsion 
must necessarily be self-limited in its duration. Suspending, as it does, 
respiratory movements, checking the oxygenation and decarbonization of 
the blood, the rapid accumulation of carbonic acid gas in the blood 
and the exclusion of oxygen, quickly puts the blood in a condition capable 
of producing the most reliable and speedy sedative effect upon the nerve 
excitability that could be found, and consequently furnishes its own 
remedy, so far as the continuance of the convulsive paroxysms is con- 
cerned. Still, for the simple effect upon the attendants, it is well enough 
to apply cold cloths to the head, warmth to the feet, sinapisms to the cen- 
tral part of the spine between the shoulders, and near the junction of 
the back with the neck, and on the center of the epigastrium; these sina- 
pisms should not be left long enough to actually blister, but simply to 
produce temporary external irritation. If the convulsion is repeated as 
soon as the patient has fairly recovered consciousness and re-oxygenation, 
it may be desirable to help shorten the paroxysm by the inhalation 
of a few drops of chloroform, or some other anaesthetic. And yet 
even this is deceptive in its supposed effects, for if the patient can breathe 
enough to take efficiently an anaesthetic into the lungs, he gets breath 
enough to quickly stop his paroxysm. It has the advantage of appear- 
ing to be doing something, and earns for the physician the confidence of 
the family, by having it appear that the use of the anaesthetic was quickly 
followed by a subsidence of the paroxysm itself. But while paroxysms 
of convulsions in children, especially those that we have now more partic- 
ularly under consideration, not dependent upon uraemic poisoning or 
retention of any toxaemic agents in the blood, but dependent directly 
upon nervous excitability aggravated by some temporary exciting cause, 
quickly subside, the treatment for preventing their recurrence has two 
clear objects to be accomplished: one is the removal, as speedily and fully as 
possible, of whatever may have acted as a direct exciting cause of the 
convulsion. If there is actually a swollen and tender gum, it may be 
incised by a clear, straight cut across the top of the tooth, sufficient to 
completely sever the gum over the tooth. But in my experience I have 
found very few instances where the slightest evidence of swollen gums 
existed as the exciting cause of the convulsion. If there be gastric or 

48 



754 CONVULSIONS. 

intestinal irritation or derangement from any cause, this should be care- 
fully corrected as early as practicable. If the child be a little older, and 
subject to undue mental excitement, passions, or emotions of fear from 
injudicious management on the part of parents, or anything connected 
with the family itself, the physician should point it out and require it to b« 
obviated. Thus, wherever the exciting cause can be traced it should be 
as accurately and fully removed as circumstances will permit. Having 
removed the exciting cause, the next and equally important object is to 
overcome the undue excitability of the nervous system, which constitutes 
the predisposition. This will often require close attention on the part of 
the practitioner and a full explanation to the parents, in order to secure 
the necessary attention for a sufficient length of time. The common tend- 
ency in all such cases is to regard the patients cured as soon as they 
cease to have convulsions and are able to take their usual food, and are 
free from immediate symptoms of disease. Consequently they become 
speedily careless about the administration of medicine, and the carrying out 
of good hygienic measures which may be essential for properly overcoming 
the constitutional morbid tendency. Therefore, to secure success in this 
part of the treatment, which often requires to be pursued for months or 
even for years, an intelligent explanation should be given to the parents 
and a proper course insisted upon. For permanent effect, great importance 
must be attached to the mode of living, including diet, exercise, clothino*, 
even more than to the administration of medicines. 

In a large proportion of this class of infants and especially young 
children after they have reached an age from two to five years, there is the 
greatest importance to be attached both to their mental and physical 
training. And first require the avoidance of all those mental influences 
which consist in encouraging periods of extreme excitement, either of 
hilarity, boisterous plays carried so far as to produce weariness and much 
vascular excitement on the one hand, and still more the avoidance of in- 
tense excitement of the passions, sudden fright, mental apprehension, that 
often are perpetuated almost from day to day by the indulgence on the 
part of parents and nurses of fretful and violent dispositions in their 
dealings with children, thereby begetting in the children themselves, 
equally violent dispositions and emotions; while the opposite kind of 
training, characterized by gentleness and kindness, if properly conducted, 
always serves to maintain better discipline than the most peremptory and 
violent commands. A very great influence can be exerted in overcoming 
the morbid nervous excitability in young children simply by proper men- 
tal influences in their management. For physical training, take them fre- 
quently in the open air riding, and when old enough to run about with any 
degree of freedom, walking and playing, varying the exercises so as to 
develop the chest and arms, as well as the legs, but avoiding all excesses 
or unduly protracted exercise. Another thing that is very generally over- 
looked, and yet of much importance to this class of subjects, is to secure 
for the patient, good, pure air during the night. Nothing tends more to 
debilitate, and at the same time increase the excitability of the nervous 
system, than sleeping in close, poorly ventilated rooms particularly if 
they are kept at an elevated temperature. Confined warm air without 
sufficient ventilation to prevent it from being contaminated by repeated 
inhalations, is one of the most injurious of all our domestic errors. There 
are many families in which the careful mothers, in their anxiety to prevent 
colds and protect their young children, keep them every night in an at- 
mosphere that is absolutely impure during all the last half of the night, 
from want of change or ventilation. So far as the administration of med- 



HYSTEKIA. 755 

icine is concerned we can only lay down this general rule: that no medi- 
cine is required other than that which is frequently needed to properly 
regulate the secretions and evacuations, using such a combination as will 
produce a soothing, quieting and tonic effect. All so-called stimulants 
should be avoided. All nervous excitants, such as tea and coffee, should 
also be avoided or used very sparingly. It is very desirable to avoid the 
use of the opiate class of narcotics, not only because they tend to consti- 
pate and interfere with secretions, but on account of the fact that they 
speedily subject these nervously excitable patients to the impression 
which calls for their repetition, and the habit of taking them is general y 
induced. Temporary quiet is obtained in such cases at the expense of 
permanent and serious impairment of the tone of the nervous system. 
The bromides in connection with tonics, either of the bitter class, such as 
preparations of cinchona, or those more directly nutrient, as the hypo- 
phosphites, lactophosphates, and sometimes preparations of iron, will be 
found advantageous. But the particular remedy must be selected for each 
individual patient, and the dose adapted to the age, always remembering 
that to overcome a predisposition or constitutional tendency of any kind, 
requires time, patience and steady perseverance. And with these three 
qualities, time, patience, steadiness of purpose, with a reasonably judi- 
cious exercise of judgment in selecting the particular hygienic meas- 
ures and remedial agents, almost all cases of the character we have been 
considering can be conducted to so full a recovery that on their arrival at 
puberty, or adult life, they will be free from the oredispositions of child- 
hood, or the defects of hereditary tendencies* 



LECTURE LXXVI. 



Hysteria— Its Varieties, Causes, Clinical History, Pathology, Diagnosis, Prognosis and Treatment. 

GENTLEMEN: Hysteria is a name which has long been applied to 
certain conditions of the nervous system presenting symptoms more 
or less similar, and yet varying widely in different cases, and very gener- 
ally regarded as limited to the female sex. Indeed, the name hysteria 
was chosen, not only because of the supposition that the disease was 
limited to the female sex, but that it was connected essentially with some 
disturbance or morbid condition of the uterus or ovaries. It is certain, 
however, that this idea of the restriction of the disease to one sex is erro- 
neous. Although occurring much more frequently in females, cases of a 
well-marked character have been observed not very infrequently during 
the early period of adult life in the opposite sex. And even in females 
there is ample evidence that many cases presenting hysterical phenomena 
have no necessary connection with the uterus or with ovarian disorders. 
Indeed, it is probable that the latter class of disorders simply act as ex- 
citing influences, tending to aggravate the nervous affection, when there 
is already existing a predisposition to it, or an actual existence of the dis- 
ease, and that the group of symptoms which are denominated hysterical, 
are in no way necessarily connected with the functions of the ovaries or 
uterus. It is a form of disease 'which has been known and described 
from a very early period of medical history, and is probably capable of 



756 HYSTERIA. 

assuming a greater number of variations in its symptoms and immediate 
manifestations thin any other disease to which the human system is liable. 
In one direction it has a close relationship to epilepsy, in another to certain 
forms of mental derangement, while the great majority of cases appear to 
consist almost exclusively in an excessive or morbid excitability of the 
Cerebro- spinal system of nerves and nervous centers, coupled with a decided 
loss of balance, or co-ordination in the controlling functions of the cerebral 
hemispheres. As already stated, it occurs most frequently in the female sex 
and between the ages of fifteen and twenty -five years, though well -marked 
instances are occasionally observed at an earlier period, and of those that 
become subject to the disease during the period named, very many con- 
tinue during the whole period of adult life. Very few cases, however, are 
observed in old age. 

Causes. — I may say, the predisposing causes consist of almost any influ- 
ence which is made to act continuously through considerable periods of 
time and of such a nature as to increase ordinary susceptibility of the nerv- 
ous structures. The confinement of young persons, from ten to fifteen and 
twenty years of age, much in warm rooms, poorly ventilated — either in 
school-rooms, in their sleeping apartments, or any other establishment, 
and especially if such confinement is coupled with active mental training, 
or any circumstances that are calculated to produce frequent mental ex- 
citements, such as the reading of novels, exciting stories, or any writings 
that intensely occupy the mind of such persons, greatly favor the devel- 
opment of that peculiar morbid excitability which renders them ready 
subjects for hysterical paroxysms of excitement. The same predisposi- 
tion to hysterical temperament is promoted by all those circumstances, 
in what is termed fashionable societ} r , which lead the young into plays 
and amusements of such a nature as are calculated to produce strong 
emotions of any kind. The attendance upon theaters, balls, or occasions 
where they, are kept till late at night in the midst of excitement, and 
usually high temperature of the air, may be enumerated as predisposing 
causes. Another unquestionable predisposing influence is that which may 
be denominated heredity. As an instance, there are families in which 
a well-marked hysterical development has been noticed from one genera- 
tion to another, through several generations. Exciting causes of hysteria 
consist in many circumstances which are calculated to produce sudden 
and strong emotions, or passions of the mind. Often a most trifling disap- 
pointment in persons predisposed will throw them into the active exhibi- 
tion of hysterical phenomena. Almost equally ready, also, will be the 
similar responses to emotions of a pleasant character, provided they are 
intense. The sudden reception of news of an exciting character, whether 
pleasant or unpleasant, and fright, will often produce the same results. 
Whenever, through hereditary influences or otherwise, a distinct hyster- 
ical temperament has been established, there is no doubt but that the 
occurrence of uterine congestion or disturbance tends to increase the 
predisposition, and to develop or induce active paroxysms of hysterical 
phenomena. In females of this class the menstrual period is almost al- 
ways one in wmich more or less of the active hysterical symptoms are 
manifested. And in some of them almost every menstrual period will be 
ushered in by full hysterical convulsions. When the sime temperament 
exists in the male, sexual excitement is liable to produce the same results 
as the menstrual period in the female. Such persons, indulging in sexual 
intercourse, or in self-abuse, will not infrequently develop directly the 
phenomena of active hysteria. 

Symptom:, — To enumerate all the symptoms observed in the various 



SYMPTOMS. 757 

shades and forms of hysteria, would require more time and occupy more 
space than would be profitable or necessary. The essential feature which 
may be said to characterize all the phenomena belonging to the hyster- 
ical condition, is that of extremes, or the production of phenomena en- 
tirely out of proportion to the nature and intensity of the exciting cause. 
And, in addition, an entire want of steadiness or balance in the manifes- 
tations of phenomena. By this I mean the rapid changing from one ex- 
treme to another. The idea is best illustrated by the very common oc- 
currence of passing from the most serious sobbing and crying in a few 
minutes to the most violent and uncontrollable laughter and hilarity. 
Such mental variations of passing from one extreme to another character 
ize all the phenomena, physical as well as mental. The motor apparatus 
may be disturbed in so erratic and variable a degree, that the patients at 
one hour claim to be powerless or incapable of motion, as though utterly 
paralyzed, and in ten or twenty minutes perhaps, are exhibiting the vio- 
lence of physical effort and full strength, or a convulsion that would re- 
quire one or two attendants to keep them in bed, or from doing them- 
selves harm. Sensations are equally variable and pass to extremes. 
More generally hyperesthesia, or claiming that the slightest touch is 
painful, often exhibiting excessive indications of pain, or suffering, from 
any touch or motion, and at other times obstinately claiming that there 
is no sensibility in the parts whatever. 

The disturbance of the involuntary functions are also characterized by 
the same extremes, as illustrated in the secretions. In one instance the 
urinary secretion may appear to be entirely suppressed, until a few hours 
or even a day has passed by with no secretion, or if any, but a few 
drops, and yet without any of the serious consequences of suppression. 
Much more frequently, however, the opposite condition exists, and while 
under the influence of active hysterical phenomena the secretion is greatly 
increased, so that a large chamber vessel may be filled in a single night. 
In such cases the urine is limpid and almost like clear water, and of low 
specific gravity. The movements of the heart, and respiration, are less dis- 
turbed in hysteria than almost any of the other functions. There is often, 
however, very great oppression or distress in the chest, sometimes in the form 
of acute pain in the left breast, at a point over the phrenic nerve, where 
it reaches the diaphragm. This might lead the inexperienced to think 
that the patient had a pleuritic, or pericardial inflammatory attack. But 
a little scrutiny would show that it was wholly unaccompanied by fever, 
or any real disturbance of the circulation and respiration corresponding 
with inflammatory disease. But more frequently the sensation of op- 
pression is in the form of a ball, or weight in the epigastric region, fre- 
quently rising up through the chest, creating the sensation of oppression, 
until it reaches the trachea, where it will appear like a ball, which they can 
neither get up nor force down by swallowing, but causes a sense of chok- 
ing and suffocation. This choking sensation is unquestionably induced 
by the transmission of a morbid impression through the recurrent branches 
of the pneumogastric nerve. Diagnostically, it has been styled the globus 
hystericus. Many hysterical patients sit up the greater part of the night, 
from dread of choking or suffocating from this sensation in the neck or 
some point between the epigastrium and trachea. In what is called a 
hysterieal fit, or full hysterical convulsion, the whole voluntary muscular 
system is thrown into violent clonic spasms, much resembling the full 
paroxysms of epilepsy. There are, however, these marked and reliable 
differences between the hysterical paroxysms and the convulsions of the 
epileptic. In the latter, the temperature rises distinctly above the nat- 



758 HYSTERIA. 

ural standard, and consciousness is totally obliterated. Bat, in the hys- 
terical convulsion, there is no rise of temperature, and it is also invaria- 
bly the case that if the patient is put to the proper test it is found that 
consciousness is not entirely obliterated during any part of the time. 
Hence, it is more rare in the hysterical convulsion than in epilepsy, that the 
same kind of accumulation of phlegm in the fauces, or what is popularly 
styled "frothing at the mouth " and biting of the tongue occur. Neither 
is there the same uniform tendency on the part of the patient, when pass- 
ing out of the paroxysm of a convulsion to have a period of apparent sleep 
as a sequel of the spasm. But the hysterical patient not only arouses 
much more readily and quickly, but also passes again quite as readily and 
quickly into another, with but a short interval in many cases, until a dozen or 
more have been encountered; and yet when they finally cease, there is 
not anything like the degree of exhaustion, and indication of serious im- 
pairment of cerebral function and sensibility that would be produced by 
even two paroxysms of epilepsy, occurring at short intervals of time. 

Those subject to hysterical paroxysms, if even of frequent occurrence, 
present none of that tendency to impairment of the mental faculties, or 
permanent changes in the functions of the brain and cerebro-spinal centers, 
which are characteristic of well-marked and frequently recurring par- 
oxysms of epilepsy. I may say then, in regard to symptoms of hysteria, 
that they consist in disturbances of the sensations and emotions, or mental 
phenomena, of almost every shape and variety of intensity and frequency 
of manifestation, from the simple choking in the neck, to the most violent 
clonic spasm. And mentally, changes from the most extreme depression 
and despondency to the highest degree of excitement and hilarity, follow 
each other in quick succession. Yet in all these variations and changes, 
they have left no impression of structural change or permanent impair- 
ment of function; consequently, a true hysterical patient may be afflicted 
for years with hardly any indications of permanent impairment, either of 
mental or physical functions. 

Diagnosis. — The statements I have just made in regard to the general 
characteristics of the symptoms and phenomena of hysteria, point to the 
most reliable means of diagnosis. There are m my phases of the disease 
in which a physician on fiist coming in contact with the patient might 
be unable at once to properly interpret. For instance, in reaching a 
patient in the midst of a violent hysterical convulsion, it might be im- 
possible during the time of the convulsion to determine by the phenomena 
alone, without an accurate history of the patient, whether it was hysterical 
or epileptic. Yet, as soon as a history of the patient has been obtained, 
or time enough has elapsed to watch the patient through the paroxysms of 
the convulsion, and a few subsequent hours, it will rarely happen that the 
practitioner will not be able to detect clearly and distinctly those exag- 
gerations, or want of balance alluded to in the phenomena that pass rapidly 
from one extreme to another in the mental and physical changes, and 
thereby readily distinguish this from all other affections. And it is on 
this careful study of the antecedents, as well as the present phenomena, 
that the physician must base his diagnosis, and not upon any one or two 
of their special symptoms. 

Pathology. — From what I have already stated in regard to the causes and 
symptoms, you will infer that there are no anatomical changes in the nerv- 
ous centers, or in any other portion of the system, that have been identified 
as characteristic of this form of disease. Indeed, it has seldom, if ever, 
terminated fatally without complication with other pathological conditions 
that are reallv the cause of death. And therefore it can hardlv be said 



TREATMENT. 759 

that there have been opportunities, except very rarely, for studying the 
minute anatomy of the nervous centers, or any other portions of the system, 
of those who have died, subject to well-marked hysteria. While, however, 
there are no distinctive structural changes recognizable in any portion of 
the nervous centers as peculiar to this form of disease, it is undoubtedly 
true that the elementary properties of the nerve structures generally are 
materially altered from that of health, and more particularly, that prop- 
erty which I have styled elementary susceptibility. This exaltation of 
the elementary property gives to the nerve tissue of the hysterical subject 
its exaggerated response to impressions of almost every character. In 
some instances, undoubtedly, this morbidly susceptible condition of nerve 
tissue is restricted to a certain portion of the nervous system. The hys- 
terical symptoms are consequently limited in their manifestations. For 
example, we see sometimes the symptoms limited to a single limb, or a 
particular portion of the body. In such cases it may take the form of 
hysterical paralysis, or some unaccountable, apparent affection of the 
joints, or of a single joint, or in the abdomen assuming the appearance of 
a tumor, constituting what is designated as phantom tumor, and which 
has sometimes so persistently simulated the existence of a tumor as to 
cause experienced surgeons to make preparation for operations, and only 
to be relieved from the deception when the patient was on the operating 
table and placed under the influence of an ansesthetic, so as to overcome 
all consciousness, when with the obliteration of the consciousness of the 
patient the tumor also disappeared. In other instances the morbid sus- 
ceptibility may be limited to certain portions of the hemispheres apparently 
affecting more particularly the manifestations of certain emotions or func- 
tions of the mind. But in the greater number of cases with which you are 
liable to come in contact, the morbid susceptibility or impressibility of 
the nervous system will be universal. I see no other way to account for 
the want of balance, the ready and exaggerated response to impressions 
of almost every kind that can be given, than by this supposed exaltation 
of the primary susceptibility of the structures themselves. As I have stated 
in the beginning, the word hysteria indicates a relationship, necessarily, to 
the uterus and ovaries, and therefore is misleading. And, as the most 
prominent and uniform characteristic of the phenomena belonging to the 
disease is that of want of balance in the performance of nervous function, 
and the extremes of response to ordinary impressions, it would perhaps be 
better if the suggestion of Dr. Hartshorne was adopted, that instead of 
hysteria, the morbid conditions included under that head now, were 
transferred to neurataxia, indicating loss of balance in the functional ac- 
tion of the nervous centers. 

Prognosis. — So far as relates to the question of danger to the patient's 
life, the prognosis in hysteria is uniformly favorable. It rarely, if ever, 
proves fatal. Regarding, however, the prospect of a permanent cure, the 
prognosis is less favorable. While many cases in the early stages of 
their progress, or even during the first few years after their development, can 
be entirely cured under favorable circumstances, there are others under 
less favorable conditions, in which palliation, and not cure, is the more fre- 
quent result of all the efforts that can be made, in the management of the 
patient. 

Treatment. — The treatment of hysteria includes two objects: the one 
relates to immediate relief of the present distressing symptoms, and the 
other to the permanent removal of the causes and pathological conditions 
which give rise to, and constitute essentially, the disease. As almost all 
of the symptoms of sufficient degree of intensity to require special pallia- 



760 HYSTERIA. 

tion consists either of spasmodic action in some portion of the muscular 
system, or the development of morbid sensations of an exaggerated char- 
acter, the remedies for temporary relief are chiefly those denominated 
anti-spasmodics and sedatives to nervous excitability. For relieving most 
of the minor symptoms which may distress the patient and prevent rest 
at night, such as oppression in the chest, sensations of choking in the neck, 
sleeplessness, and various grades of mental excitability and hallucination, 
a combination of the bromide of ammonium with some preparation of 
valerian, scutalaria, or hvosciamus, or of the three combined in proper propor- 
tion will usually suffice for administration at the proper time, and in suit- 
able doses. A prescription, consisting of fluid extract of valerian, sixtv 
cubic centimeters (fl. 3 ij), fluid extract of scutilaria forty-five cubic cen- 
timeters (fl. § ij), fluid, extract of hyosciamus fifteen cubic centimeters 
(fl. 3 iv), and bromide of ammonium twenty grammes (3 v) may be given 
to a patient, between the ages of fifteen and twenty-five years, in doses of 
four cubic centimeters, (fl. 3 j), diluted with a little additional sugar and 
water, early in the morning, at tea time and bed time. 

In the cases to which I last alluded, it will seldom fail to relieve the 
morbid sensatious, produce a degree of quiet during the day, and secure 
for them a fair degree of sleep during the night. Many times I have found 
that two doses, one at tea time and the other at bed time, were quite suf- 
ficient for accomplishing these purposes. AVhere the disease manifests 
itself in the form of neuralgic pains, whether in the left breast or in 
almost any other part of the system, valerianate of ammonium is one of 
the most efficient remedies that can be used, so far as my observation ex- 
tends. This remedy, given in doses of from six to twelve centigrammes 
(gr. i to ij) three times a day will usually afford the desired relief. Where 
full convulsions occur the immediate administration of an enema, contain- 
ing six decigrammes (gr. x) of assafcetida, and the same quantity of hydrate 
of chloral suspended in sixty cubic centimeters (fl. 3 ii) of warm water or 
mucilage, and. introduced into the rectum, will usually produce a prompt 
and decided degree of relief. As soon as the spasm has passed suffi- 
ciently to allow the patient to take remedies by the mouth, a gelatine- 
coated pill of three grains of assafcetida may be given, and repeated 
every two hours till the disposition to further convulsive movements cease. 
In such cases, where full convulsions occur, it is often justifiable also to 
apply sinapisms over the epigastrium and warmth to the extremities; and 
when the sinapisms have been applied until the skin is red, changing it 
to the central portion of the spine between the scapulas, will also produce 
some influence in relieving the patient. I have mentioned the foregoing 
remedies simply as specimens, and to indicate to you the class of reme- 
dial agents that may be made useful for temporary purposes in relieving 
the various forms and shades of hysterical excitement and active phenom- 
ena. In the more protracted and severe cases, especially involving con- 
vulsions, chloroform and ether may be called into requisition temporarily. 
But so far as the cases can be managed without inducing direct anaesthe- 
sia on the one hand, and more particularly without the use of opiates on 
the other, it will be desirable to do so. There are no classes of patients 
that so readily become habituated to the use of either anaesthetics or 
opiates as the hysterical. And none are more difficult to relieve from the 
habit, especially of the use of opium, where they have once acquired it. 
And not only this, but opiates are objectionable in this class of patients, 
for the reason that while they may prove efficient in temporarily quieting 
the hysterical excitement, inducing rest and relieving spasms, they inva- 
riably produce more or less derangement of the digestive functions and 



TREATMENT. 761 

secretions, and pave the way for a return of the active symptoms of the 
disease more readily than though they had not been used. Consequently 

it is desirable always to avoid their use in this class of subjects as far as 
practicable, and my own experience has satisfied me that the cases in 
which they are strictly necessary are exceedingly rare. The same re- 
marks apply to the use of the alcoholic class of anaesthetics, either fer- 
mented or distilled. 

No class of subjects more readily become habituated to them, or claim 
that they relieve their varied and excessive exaggeration of nervous evils, 
than the hysterical. And yet, their effects are always temporary, never 
curative, and directly calculated to perpetuate the constitutional difficulty 
under which the patient labors. In regard to the other object of treat- 
ment, namely, the removal of the diathesis or constitutional tendency, or, 
in other words the removal of the disease, there are no specific remedies to 
be recommended. Each case must be studied by itself; the causes, pre- 
disposing and exciting, which influence the individual patient, must be 
accurately ascertained, and as far as possible they must be removed or 
avoided by removing the patient from their influence. Wherever special 
functional disturbances exist, such as indigestion, constipation of the 
bowels, suppression of the secretions of any kind, derangement of the 
uterine function, or menstruation, all of these must be noted and remedies 
employed appropriate for their removal. When, as far as practicable, the 
predisposing and exciting causes have been removed, and collateral dis- 
turbances that may act injuriously upon the patient in perpetuating the 
nervous derangements, are corrected, the remainder of the treatment 
will consist in procuring for the patient an abundance of pure air, moder- 
ate and regular systematic outdoor exercise, and above all the influence of 
steady, pleasant mental occupation. Something to do every day, and 
something which will actuallv engage the thought and attention, as well 
as absorb the time of the patient, is of paramount importance. There is 
no obstacle in the way of the cure of these patients greater than that of 
idleness or want of occupation. And no part of the management is more 
difficult in many cases than supplying such occupation as is needed. But 
plain, unstimulating diet, good air, warm clothing during the cold 
seasons of the year, careful attention to the digestive function, and regu- 
lar pleasant occupation of the mind, will cause almost any hysterical sub- 
ject to obtain permanent relief from her difficulties. A considerable 
number of these patients present a moderate degree of anaemia or slight 
impoverishment of the blood, and will be benefited by the protracted use 
of moderate doses of iron, combined with the milder class of anodynes. 
A combination of citrate of iron and hyosciamus, thirteen centigrammes 
(gr. ii) of the former and six (gr. i) of the latter, put up in the form of a 
gelatine-coated pill or capsule to render it pleasant for the patient to 
take, may be given at each meal time. This remedy will often do much 
to improve the general tone of health, and consequently lessen any undue 
susceptibility of the nervous system. If the patient lives in a malarious 
district, and has been more or less subject to the impairing influence 
of that agent, six centigrammes (gr. i) of quinine or cinchonidia may be 
properly added to the pill of iron and hyosciamus. But it is useless to 
specify particular tonics, for if you see clearly the objects to be accom- 
plished, namely, that of holding a steady, moderate, quieting influence 
over pure excitability on the one hand, and promoting a more act ve 
development of blood corpuscles and efficiency of nutrition upon the 
other, you can easily select from the materia medica an ample supply of 
those agents which will be calculated to fulfill these indications. What- 



7G2 INSOMNIA. 

ever agent is used, however, should be given in moderate doses with the 
expectation of continuing it through a considerable period of time. The 
administration of medicine of any kind should never cause the physician 
or patient to lose sight of the value and necessity of occupation, outdoor 
air and the avoidance of extreme excitement in all the relations of life. 

Ilysiero-epilepsy . — A class of cases that recently attracted much atten- 
tion, "chiefly through the investigations of Charcot and others in Paris, 
may be styled hystero-epilepsy, or a combination of the phenomena of 
hysteria and epilepsy in the same person. Thus far, all the cases that 
have been presented of this particular class are females, usually in the 
early period of adult life. Some of them have exhibited very remarkable 
phenomena in varying from the occurrence at irregular intervals of slight 
muscular rigidity, sometimes accompanied by increased sensibility or 
hyperesthesia, and at others by ana3thesia, or loss of sensibility, to the most 
violent convulsions. The phenomena are sometimes limited to particular 
parts as one limb or one half of the body, and at others, involving the 
whole muscular system. In an}'- stage of the progress in these cases even 
coincident with the convulsive paroxysm, there are presented the most 
remarkable emotional manifestations and the assumption of the most gro- 
tesque and ludicrous attitudes. Some of these cases have been studied and 
exhibited in the clinics of Charcot, and have attracted a great deal of 
attention. The point of most interest, however, connected with them is 
the apparent demonstration of the relationship between the ovaries and the 
manifestation of the general symptoms. Several of the cases that have 
been exhibited in the clinics, and some that have been studied elsewhere, 
were found capable of manifesting muscular rigidity, and passing through 
all the stages that I have just alluded to by simply making light pressure 
over one or both ovaries. 

And yet, firm and strong pressure over those parts would pretty gen- 
erally arrest the further progress of the paroxysms. So much so indeed, 
that pressure upon the ovaries has been proposed as a temporary mode of 
relief, and the extirpation of these parts suggested as a permanent means 
of cure. A study of these cases has brought out phenomena so striking, 
and in some instances bearing such close resemblance to the nervous af- 
fections that have occasionally appeared like epidemics in connection with 
high religious excitement in the past three centuries, both in Europe and 
in this country, that they have been considered as affording an explana- 
tion of the phenomena that were manifested on those occasions. Aside 
from the local treatment relating to the ovaries, these cases require to be 
managed upon the same principle that we have already mentioned in re- 
gard to hysteria in general. 



LECTURE LXXVII. 



Insomnia and Neuralgia— Their Varieties, Causes, Clinical History, Pathology, Diagnosis, Prog- 
nosis, and Treatment. 

GENTLEMEN: By insomnia is meant inability to sleep. If not a 
distinct disease it is a morbid condition of not very infrequent oc- 
currence and may originate from a variety of causes. From the most 
recent and careful investigations it would seem that the condition of sleep 



TREATMENT. 763 

is one in which there is less fullness of the arterial circulation in the 
brain, a state of less activity of the circulation in the arterioles, 
while that of wakefulnt ss and insomnia pathologically is the opposite. 
In the latter condition, from some cause the arterioles remain excited and 
maintain a morbidly increased activity of circulation, fullness of blood, 
or a state of erethism, as it has been termed by some. This condition is 
capable of being produced by prolonged and intense mental application, 
perhaps, still more rapidly by intensity of mental emotions, whether 
depressing or exalting, also by apprehension, anxiety, particularly in ref- 
erence to business concerns, or too great a variety of important objects to 
be attended to, so that the mind is over-burdened. These are among the 
most common causes of insomnia. The first, or protracted mental appli- 
cation, is the one most frequent among students and literary men. That 
dependent upon mental apprehension and intensity of thought, or anxiety 
about results is most apt to be the one affecting business men. But all 
classes of individuals, male and female, are liable to encounter such men- 
tal conditions, and be involved in such circumstances as may lead to this 
condition of undue cerebral excitement or erethism in the brain. There are 
some agents in common use that are capable of Droducing the same con- 
dition. Of these, strong tea and coffee are among the most common, and 
there are thousands, especially in the female community, and even among 
servants in our houses, who by the habitual use of strong tea create a 
condition of insomnia coupled with disturbance of the functions of the 
pneumogastric and cardiac nerves, that prevents sleep night after night, 
sometimes for months, until the general health is much impaired. A 
somewhat similar condition, though differing a little in its phenomena, is 
sometimes induced by the excessive use of tobacco. Alcohol, by its 
excessive and protracted use produces insomnia, but the phenomena are 
connected with other symptoms so as to distinguish it from the ordinary 
cases and give it such characteristics as have been described as delirium 
tremens, or mania potu. The disease to which I now allude is not one of 
delirium, however, nor one of mental derangement in any sense, but 
simple inability to sleep. Sometimes, though not frequently, extreme 
exhaustion from over-exertion may produce this condition, but if so it is 
rare. If insomnia depends upon the condition to which I have just 
alluded, and may arise from the causes enumerated and others acting in 
a similar direction, it is not difficult to select the remedies that may be 
most efficient for relieving the difficulty. 

Treatment. — The first and most important item in the treatment is the 
removal of the cause, or suspension of its further action whatever it may 
be. If the use of tea, coffee or tobacco in excessive quantities has been 
the exciting cause, it must be discontinued. If intense mental exercise, 
protracted mental application, or an excess of business cares excites ap- 
prehension, little can be expected in the way of success in relieving the 
patient without mitigating or removing the action of these causes. And 
the patient must be informed that a change which will relieve him of all 
excess in any and all of these directions is an absolute necessity for 
obtaining the relief that he desires. 

The same rule will apply to the removal of any and every variety of 
cause that might be of influence in developing the disease. There is a 
great temptation to neglect this in many of these case-, especially as they 
occur among men largely engaged in business or intently occupied in 
literary pursuits who, by administering palliatives, endeavor to palliate 
the morbid condition, while allowing the cause to continue. The claim is 
that the patient must accomplish this or that task or object, and that relief 



704 INSOMNIA. 

must be procured by agencies that will overwhelm the effects of the ex- 
citing cause. All such cases present a strong motive for using anodynes 
and anaesthetics of the stronger class, which by their use always en- 
danger developing a condition of the nervous system far more injurious 
than the one they are endeavoring to palliate. It happens in many of 
these cases that either by the recommendation of the physician or from the 
previous knowledge of the patient himself, but more frequently from the 
advice of some of his neighbors, he commences to procure sleep by taking 
a certain amount of alcoholic drink every night. In mild cases it will be 
a glass or mug of beer, ale or porter. In cases of greater severity, whisky 
sling or punch will be called into requisition, and under these they will 
claim to sleep. There are large numbers of those who commence to pal- 
liate the effects of injurious mental exercise and surrounding circum- 
stances by using these agents, at first, simply for the purpose of procuring 
sleep. But they soon create that condition of the system by which they are 
inJuced to use them more and more frequently, until before they are 
aware of it they have become completely enslaved by the alcoholic anaes- 
thetic. After acquiring this condition it is more difficult to cure by far 
than the original disease. If instead of alcoholic anaesthesia, they have 
assayed to palliate their symptoms and enforce sleep by any of the opiate 
preparations, they have generally ended in the development of the 
opium habit which, though not so destructive in other respects, is more 
difficult to eradicate than the alcoholic enslavement. The physician can not 
be too guarded against allowing this class of patients to enter upon the 
use of either the alcoholic or opiate preparations. It is the imperative duty 
of the physician in all these cases, instead of yielding to the use of such 
agents for the purpose of allowing the patients to continue the operation 
of the causes which have impaired their ability to sleep, to require the 
immediate removal of the latter. He may afford such aid as can be 
done without resorting to injurious medication, or such as will endanger 
the development of morbid appetites and injurious habits. In my own 
experience I have encountered no insuperable obstacles in carrying out 
the measures which I have just now recommended. Patients will seldom 
be found so obstinate or blind to their own interests that they will not 
make the necessary changes in their business and habits, if the physician 
clearly explains the tendency and causes of their trouble and familiarly 
points out to them the necessity for modifying and removing them. 

Nineteen twentieths of all cases of insomnia, if the causes are avoided,will 
readily yield to the use of a moderate amount of any one of the bromides, 
either alone or in conjunction with digitalis. From six to thirteen deci- 
grammes (gr. x to xx) of the bromide of potassium or ammonium, with the 
same number of minims of the tincture of digitalis, for an adult, adminis- 
tered from half to three quarters of an hour before the patient desires to 
go to sleep, will produce the desired effect, and obtain comfortable sleep at 
night. In cases of more obstinacy, the dose I have just spoken of adminis- 
tered about seven o'clock in the evening, and repeated at nine or half-past 
nine, thus making two doses in the evening, will rarely fail to pro- 
cure the desired sleep. Chloral is often resorted to, but after a fair 
trial, I have abandoned its use in this class of patients from the fact 
that very many of them, while they sleep during the night, and 
especially during the latter part of the night, or even until late in 
the morning, continue to feel during most of the following day, a dull, 
stupefying effect upon their mental faculties that is not pleasant. And 
sometimes they exhibit a degree of dullness amounting to an incapacity 
to attend to any business even of the lightest character. This tendency 



TREATMENT. 765 

to perpetuate the dull, stupefied condition of the cerebral function during 
the following day, renders the use of chloral less desirable than the bro- 
mides, and so far as 1 have been able to observe it is not in any degree 
more efficient. In some few instances 1 have known at first, until a par- 
tial recovery had taken place, a combination of the bromide and chloral 
to do better than chloral alone. As you will perceive also, I usually give 
a dose of digitalis it) connection with the bromides. Direct clinical ob- 
servation, first in the treatment of delirium tremens, has led me to regard 
digitalis as possessing much efficacy in diminishing that peculiar erethism, 
or morbid excitability of the brain which prevents sleep, more particularly in 
that class of cases where the general condition is one of impairment, not of 
anaemia proper, but where the pulse is rather quick and irregular, with un- 
due nervous excitability in addition to wakefulness. In all this class of 
cases, the influence of digitalis in giving more steadiness, slowness and 
uniformity to the heart's action, renders it an advantageous agent, and aids 
very much the more purely sedative effect of the bromides upon nervous 
excitability, and contributes largely to the recovery and re-establishment, 
permanently, of a more normal condition of the circulation than could be 
obtained without its use. It is probable that the fluid extracts of cactus 
grand i flora, and of con vail aria would produce effects very similar to those 
that are obtained from digitalis. In some instances, also, valerian com- 
bined with the bromides will contribute decidedly, not only in the pro- 
duction of sleep during the night, but by a pleasant tonic influence 
upon the nervous system contribute much in establishing its proper 
tone. It is unnecessary to say that in all these cases, in addition to rem- 
edying the causes that have operated injuriously upon the mind, 
attention should also be given to the physical functions of the patient. 
Constipation should be obviated, indigestion should be mitigated, and at- 
tention should be given to the natural condition of all the functions of the 
body, as well as the removal of such causes as might be already more 
especially disturbing the functions of the brain. A few words more in re- 
gard to another subject — night terrors. I allude to cases which are met 
with more particularly in children and youth, in which they become sub- 
ject, not every night, but often, to starting suddenly in their sleep, as if 
greatly terrified. More generally, it occurs during the first sleep after re- 
tiring to bed. The child has been placed in bed, falls asleep quietlv, ap- 
parently in good health, and in from one to two hours, suddenly "starts 
up, looking wild and anxious, crying out for its mother or its attendant, 
as if in extreme terror; the shrieking may be for something to go away, 
as if in immediate danger of some terrible infliction. Afterthe mother or 
attendant comes to its rescue, it pays no heed to her, but continues the 
same phenomena, exhibiting the most intense excitement and fear both 
in its utterances and in its motions. Notwithstanding the shrieks and cries 
the child is still asleep while in the midst of these terrors. Cases are 
occasionally met with in which these night terrors occur so frequently 
that they seriously disturb the child's sleep; and it becomes peevish 
habitually and more or less nervous or excitable, constituting an appreciable 
impairment of the general health, besides being a source of great anxiety 
to the family in which it belongs. The treatment required in such cases 
consists, first, in the adoption of some means for arousing the patient from 
his condition of terror, and secondly, in preventing its recurrence. 
The first is generally most easily effected by the simple process of im- 
mediately bathing the child's face with a cloth wet with cold water. 
The application of a cold, wet cloth over the face and forehead quickly 
arouses it from the condition of terror to one of wakefulness, The 



766 NEURALGIA. 

moment it is thus aroused, it looks about, recognizes its friends and then 
generally resumes its attitu ie for rest, and in a few minutes is again 
asleep. There are some instances in which these terrors will come several 
times during the same night, but more frequently they occur but once, the 
patient often going to sleep the second time, and sleeping quietly through 
the remaining part of the night. The treatment for preventing their re- 
currence must depend upon a careful examination of the patient with a 
view to determining the cause or causes from which this condition may 
come. Sometimes it is taking food too late, and retiring with food un- 
digested in the stomach. Sometimes it maybe attributable to excesses in 
exercise of some kind during the day, especially in the latter part of the 
day; or it may arise from excessive mental exercise, or the indulgence of 
intense emotions and passions. A careful examination into the temper 
and habits of such children will often enable the physician to see more 
clearly the causes which exercise a disturbing influence over the functions 
of the brain during sleep, and by immediate removal of these causes there 
will be little else required to procure exemption from a return of the 
attacks. 

But where the causes are not fully apparent, where the functions of the 
body are well performed, and there is no appreciable error in the mental 
influences that bear upon the patient, and still these paroxysms take place, 
jt indicates a morbid state of the brain in which sleep develops into one 
of only partial inactivity accompanied by a constant tendency to frightful 
dreams, which give character to the special phenomena of such attacks. 
The remedies that are most likely to succeed in preventing such attacks 
are the same I have spoken of as being the most successful in cases of 
insomnia; that is the bromides and digitalis, or the bromides with vale- 
rian. Either of these combinations given in doses calculated to produce a 
decidedly quieting effect, a little before the patient go^s to sleep, will 
usually secure exemption from the periods of excitement and dreaming 
till the tendency is finally eradicated. While I think the combinations 
I have just mentioned are the best, they are by no means the only ones 
that may be used. Chloral hydrate, hyoscyamus and camphor, either 
separate or combined, will generally produce the desired result, more es- 
pecially if attention is given at the same time to keeping the various func- 
tions of the body in order, and to the proper regulation of the diet and 
exercise of the patient during the day. 

Neuralgia. — Neuralgia, by which is meant pain in a nerve, is one of the 
most common affjetions the physician is called upon to treat. It may oc- 
cur in any of the nerves of sensation derived from the spinal cord or brain, 
but is perhaps most frequent and troublesome, and consequently most 
likely to call for the attention of the physician, in the nerves of the face, 
sometimes taking the form of what has been styled tic douloureux, in the 
sciatic nerve, called sciatica, in the phrenic and intercostal nerves, gener- 
ally called pleuro-dynia, and in the nerves of the stomach, called gas- 
trodynia or gastralgia. These are names derived merely from the nerves 
in which the pain makes its appearance, and not from any differences 
in the nature of the affection. Neuralgia as distinguished from the 
pain produced by inflammation, either in the nerves or in the nervous 
centers, may be referred to three pathological conditions: one, in which 
the morbid sensitiveness is developed in the nerve itself or in the fibrous 
sheath directly surrounding the nerve matter; another consists in a morbid 
condition developed in the nervous centers, either in the spinal cord or 
brain, the manifestation being shown in the peripheral extremity of one or 
more nerves; and the third pathological condition favorable for causing 



SYMPTOMS. 767 

neuralgic pains, is an impoverished or spansemio condition of the blood, or 
the presence in that fluid of some toxsemio ingredients derived from with- 
out. The first of these pathological conditions, namely, that relating to 
the nerve, or its sheath, most frequently consists of an inflammatory con- 
dition of the sheath arising from exposure to cold and wet, closely akin 
to rheumatic irritation, causing the sheath of the nerve to be more vas- 
cular, and consequently making pressure on the nerve matter, inducing 
pains which are denominated neuralgic. The same effects may be produced 
bv the pressure of tumors in the course of a nerve, or by thickening of the 
periosteum in the bony orifices through which nerves pass in emerging 
from the spinal canal or cavity of the cranium. 

In all such cases the neuralgia is characterized by being uniformly 
manifest in the same nerve and its branches, instead of radiating in dif- 
ferent nerves. Familiar illustrations of this variety of neuralgia are 
found in the thickening of the periosteum and sheaths of the nerves of 
the face as they make exit from the different orifices, especially in the 
patients that are laboring under constitutional syphilitic difficulty, as well 
as those which may be accompanied by chronic rheumatic affections of 
the same tissue. Another very common example is sciatica, by which is 
generally meant a painful affection of the sciatic nerve, induced in most 
cases by rheumatic inflammation, affecting the sheath of the nerve and 
the fibrous tissue, at the orifices through which the roots of the nerve 
emerge from the spinal cord. The second class of cases of neuralgia are 
those which depend upon some influence in the nervous centers, and the 
pain is seldom restricted to a single nerve or its branches, but is found to 
radiate through a number of nerves, having origin or connection with the 
same portions of the nervous center, but distributed, perhaps, in differ- 
ent directions. Wherever the neuralgic pains thus vary from one nerve to 
another, either in the trunks of the nerve or in the branches derived from 
different nerves in quick succession or simultaneously, it is evident that there 
is either primary or reflex irritation established in the nervous centers to 
which those nerves belong. The third class, or those which are dependent 
on the condition of the blood or the action of some toxaemic agent in that 
fluid, differ from both the preceding in the pains being felt sometimes in 
one part and sometimes in another, until almost every sentient nerve will 
be found to be in turn more or less affected. The pains are usually of very 
short duration at any one point, but are frequently repeated and generally 
very acute while they last. Familiar examples of this variety of neuralgia 
are found in patients subject to gout or rheumatic gout, not infrequently 
from the influence of malaria in impoverishing the blood. 

Diagnosis. — Diagnostic features of neuralgia, by which it is to be dis- 
tinguished from the pains dependent either upon the febrile conditions or 
local inflammations, are chiefly, the sudden development of the pain, its 
equally sudden disappearance, usually, entirely unaccompanied by any 
constitutional disturbance, either of increased temperature or disturbed 
circulation and in the interval between the paroxysms of pain, almost 
entire exemption from tenderness or increased sensitiveness of the part af- 
fected, although increased sensitiveness of the part is often present during 
the attacks of pain. There are different degrees of severity in neuralgic 
pains. Some are slight and momentary, others are sharp twinging or 
pricking; and still others so excruciating, piercing, and severe, as to cause 
the most agonizing suffering of which we can conceive. While they vary 
thus in the degree of severity, their most characteristic feature is suddenness 
of development and equally sudden disappearance; they are always paroxys- 
mal, never continuous beyond a very brief period of time without interrup- 
tion. 



768 NEURALGIA. 

Patholoyy. — In speaking of the causes which may give rise to neuralgia, 
I intimated at the same time, the essential pathological conditions. Per- 
haps, in the nerve itself, it may be said that the essential pathological 
condition is an exaltation of the susceptibility of the nerve structure. 
There are no changes of such a character as to be perceptible or recogniz- 
able in the arrangement of the nerve cells, or the intricate structure of the 
nerve matter, which can be said to be characteristic of neuralgia. But the 
disease appears to be purely of a functional nature, not necessarily ac- 
companied by structural changes. As I have just remarked, it consists in 
the development of a morbid degree of susceptibility, sometimes accom- 
panied by pressure from congestion, thickening or induration of some por- 
tion of the nerve sheath or connective tissue surrounding the nerve. In 
such cases the continued pressure on the nerve tissue sometimes, if of long 
duration, results in atrophy, or wasting of the nerve cells, and increase 
or sclerosis of the connective tissue in which the nerves are contained, con- 
stituting a true sclerosis of the nerve cord. Those cases of neuralgia 
which are not traceable to local conditions relating to individual nerves, 
but are manifestly derived from some morbid condition of the nervous 
centers, often afford no indications of structural change that can be identi- 
fied as a cause of the neuralgic difficulty. The same is true to an equal 
extent in regard to those neuralgias thac are dependent on changes in the 
condition of the blood. 

Treatment. — From the brief review I have given of the nature, 
symptoms and causes of neuralgia, you will have inferred that no method 
of treatment can be recommended as applicable to the cure or removal of 
all cases indiscriminately. But every case must be treated in accordance 
with the indications it may afford on careful examination in reference to the 
causes and pathological conditions which give rise to it. It may, indeed, 
be said that the object in the treatment of neuralgia is two-fold: one sim- 
ply to mitigate pain, and consequently the suffering of the patient, for 
temporary relief; the other curative, or having for its object the removal 
of the causes and pathological conditions giving rise to the pain. The 
first may be accomplished by almost any efficient anodyne or anaesthetic; 
but the effect is temporary, and only relieves the patient while the anodyne 
or anaesthetic effect is maintained, unless other measures are adopted 
simultaneously for removing the cause. It is not desirable that patients 
become accustomed habitually to the use of opiates and anaesthetics 
for the temporary relief of their sufferings, so long as it is possible by any 
form of treatment to remove the cause; for, once habituated to the influ-| 
ence of these agents, they become a serious injury to the patient's health 
and happiness, and sometimes create a morbid condition of the nervous 
system, more difficult to eradicate than the original disease. My own 
observation has shown that a considerable proportion of those who become 
habitual opium eaters, or users of large quantities of morphine, have 
commenced, and gradually developed their habit for the purpose of reliev- 
ing some form of neuralgia, or temporarily mitigating some painful affec- 
tion that should have been relieved in some other way. Consequently, 
while chloroform, and other anaesthetics, morphine, and especially mor- 
phine and atropine combined and used hypodermically, may be resorted to 
for promptly relieving neuralgic pains of unusual degrees of intensity, yet 
I am satisfied that it is better to dispense with such remedies as early 
and to as great a degree as can be done and allow the patient to get any 
reasonable degree of rest during the time that the more curative treat- 
ment is carried out. The curative measures must, of course, depend up- 
on the pathological condition giving rise to the neuralgic disease. Where 



TREATMENT. 769 

the fault is in the condition of the blood, either by the retention of toxe- 
mic and irritating ingredients, as in gout, rheumatism, malaria, or vari- 
ous other agents capable of acting through the blood upon the nervous 
system, the remedies chosen must be such as are known to be most effi- 
cient in removing these agents, and these, I have already pointed out to 
you when speaking of the treatment of gout, especially neuralgic gout, 
rheumatic gout, and in the treatment of malarious fevers, and their vari- 
ous sequelae; consequently it is not necessary to re-enumerate the 
remedies for these purposes at this time. Many cases of neuralgia that 
are dependent upon malarious influences coupled with impoverishment of 
the blood have a strict periodicity, almost as much as the ordinary parox- 
ysms of intermittent fever; coming at stated times in the day, and some- 
times every second or third day, but without the accompaniment of fever 
or chills. All such cases require the efficient use of quinine or other relia- 
ble antiperiodics. At the same time due attention should be given to the 
use of such tonics or nutrients as will most efficiently promote the forma- 
tion of red corpuscles, and the restoration of a healthy condition of the 
blood. Those cases of neuralgia dependent upon a morbid condition af- 
fecting the nervous centers, either in the spinal cord or in the brain, can 
be removed only by removing the central pathological conditions. Some- 
times these consist in the development of tumors, pressing upon some 
portion of the brain; hasmatoma, induced in advanced life, in connection 
with pachy-meningitis; and not infrequently those changes caused by 
sonstitutional syphilis, either in the production of thickening of the dura- 
mater, causing pressure upon the brain or spinal cord of the same nature 
with thickening of the periosteum or the bones of the extremities, or by 
the degenerative change styled syphiloma, affecting the nerve struct- 
ures. All these are conditions capable of giving rise to the most annoy- 
ing and protracted neuralgic affections, such as hemicrania or migraine, 
facial neuralgias, sometimes severe neuralgic pains in the arms, especially 
near the insertion of the deltoid muscles, and occasionally radiating 
through the pneumogastric, as far as the stomach, causing violent parox- 
ysms of gastrodynia. One case came under my own observation within 
the last two or three years, in which an adult, in the early period of life, 
had suffered for a number of years with the most severe neuralgic pains 
usually affecting the nerves of the head, the posterior muscles of one side 
of his neck extending down to the shoulders as far as the insertion of the 
deltoid at times, and which in its later stages became associated with 
more or less paralysis and with temporary turns of unconsciousness, usu- 
ally not lasting more than a few hours at a time. This patient ultimately 
died under well-marked symptoms of cerebral disease, and the post mor- 
tem revealed a tumor, evidently originating from the dura-mater im- 
bedded in the posterior lobe of the left hemisphere of the brain, fully two 
inches in diameter and in structure presenting all the appearances of a 
sarcoma. Of course when neuralgia, either alone or complicated, depends 
upon such structural changes as are in themselves incurable, no amount 
of treatment will do more than palliate the suffering of the patient, until 
a fatal result is reached. If you study closely the general diathesis of the 
patient, the influences, hereditary or otherwise, which may have existed, 
and capable of leading to deteriorative changes in some portions of the 
nervous system, you will generally be able to comprehend clearly the 
nature of the case you have to treat; and in those that are capable of re- 
moval, to adopt such treatment as will be successful in accomplishing that 
result. Of course, in those subject to constitutional syphilis, or to tuber- 
cular disease, the course of treatment must be guided by the nature of the 
49 



770 TETANUS. 

pathological changes belonging to each case. These have already been 
discussed when speaking of the various constitutional diseases. The 
form of neuralgia which is most common and most amenable to judicious 
treatment is that which depends upon some pathological condition relating 
directly to the nerve in which the pain is located. Yet such of these as 
depend on a permanent thickening of the dura-mater or of periosteum in 
the orifices of bone through which the nerve trunks pass, or on indura- 
tions that have become permanent in the sheath of the nerve, are incura- 
ble unless some operative procedure can be brought to bear, such as re- 
moval of a section of the nerve on the central side of the point of pressure 
or disturbance, which is sometimes not practicable. In those dependent on 
syphilitic, rheumatic or gouty influences, the treatment usually available 
for the removal of the constitutional aifections, if adopted and pursued 
steadily through a considerable period of time will afford the patient relief. 
In several cases, both of hemicrania and facial neuralgia, which had ex- 
isted for a long period of time and had been regarded as incurable, I found 
the patients to recover permanently by causing them to use steadily 
through several weeks of time a combination of the iodide of sodium and 
bichloride of mercury with conium in moderate doses, but persistently 
three times a day, in the same manner as for treating syphilitic nodes on 
any of the exterior portions of the extremities or cranium. By pursuing 
such a course, on the supposition that the difficulty was a thickening of 
the sheath of the nerves, or at the point of their exit from the cranium or 
spine, such supposed thickening has disappeared, or, at least, the neural- 
gias have been cured, and the patients in all respects improved in their 
health and physical condition. In a word, then, the curative treatment of 
neuralgia consists in ferreting out as accurately as possible the patholog- 
ical condition on which it depends, and adjusting the use of remedies in each 
individual case to the removal of such condition, whether in the blood, in 
the nervous centers or in some portion of the individual nerve in which 
the pain is located. 



LECTUEE LXXVIII. 



Tetanus— Its Causes, Clinical History, Pathology, Diagnosis, Prognosis and Treatment. 

GENTLEMEN: The next subject to which I will direct your attention 
is one much less common, but far more destructive in its effects, when 
it does occur, than that which has just occupied your attention. Tetanus 
is a disease affecting the nervous system, which has been known and 
described since a remote period in the history of medicine. It consists 
essentially in such a pathological condition of some portion of the nerv- 
ous centers, generally in the spinal cord, as will induce continuous, rigid 
muscular contraction accompanied by exacerbations of greater intensity, 
during which there is not infrequently clonic spasms. But the character- 
istic feature of the disease is continued rigid muscular contraction, with 
more or less intensity of pain. In the great majority of cases the first 
indications of the disease are felt in the muscles that move the lower jaw, 
causing that degree of rigidity of the temporal and masseter muscles, and 
sometimes other muscles of the neck, that renders it difficult and painful 



SYMPTOMS. 771 

to open the mouth; and when the disease is fairly developed, rendering 
it, in most cases, impossible for the patient to open the mouth or separate 
the teeth far enough to allow the taking of eve u liquids without much dif- 
ficulty. In most cases, soon after the rigidity of the muscles of the jaws 
has made its appearance, a similar degree of rigidity begins in the mus- 
cles of the back of the neck and along each side of the spines of the ver- 
tebrne. From the first, it is difficult for the patient to bend his neck or 
turn his head, and soon the contractions of the dorsal muscles draw the 
head backward and bend the whole body, making it convex anteriorly and 
curved or concave along the spine. This rigid contraction curving the 
spine backward, causes great pain to the patient, particularly through 
the direction of the diaphragm, the chest and the epigastrium, but more 
especially directly through the central portion of the body in the line of 
the diaphragm. The tetanic contraction of the muscles is continuous, 
allowing no positive relaxation at any period of time during the progress 
of the disease. But while there is constant rigidity or contraction there 
are also frequent paroxysms of still greater contraction of a temporary 
character, constituting paroxysms of spasmodic action in which, some- 
times, all the voluntary muscles are called into action and may be more 
or less rigid. The patient is placed in extreme suffering, it being difficult 
for him to obtain breath, and causing the tension and tightness through 
the central portion of the body to be extremely distressing. 

In the mean time while this peculiar muscular rigidity, manifested 
mostly in the muscles of the jaws and along the spine, continues, with the 
intervention every few minutes of more decided cramps and distress, the 
disturbances of temperature and circulation are only moderate. The tem- 
perature rises but little above the natural standard in the great majority 
of cases; the pulse usually becomes moderately increased in frequency, 
rather soft and weak, the extremities cool, lips looking a little dry, the 
countenance anxious in its expression, deglutition more or less difficult, 
respiration rendered inefficient and unsteady on account of the frequent 
spasmodic contractions of the diaphragm and thoracic muscles, but the 
discharge of urine and faeces often continues nearly natural. The symp- 
toms I have described are such as characterize the great majority of cases 
during the first three or four days after the development of the disease. 
If no relief is obtained during that time, the patient's strength begins to 
fail somewhat rapidly, the pulse becomes small and frequent, the mind 
sometimes wandering, the extremities become cold, bluish, the spasmodic 
paroxysms increase in frequency and severity, sometimes bending the 
body backward almost into a half circle and creating the most intense 
distress at the epigastrium, almost entire inability to perform the act of 
deglutition, involuntary discharges, particularly at times during the vio- 
lent spasmodic paroxysms, and in two or three days more complete exhaus- 
tion and death supervene. Cases of a little more moderate character 
may continue from nine to fourteen days and yet prove fatal from exhaus- 
tion. Perhaps a majority of cases of tetanus of every variety terminate 
fatally between seven and nine days. Occasionally a case is met with 
especially of traumatic origin which will run a more protracted course, 
the tetanic rigidity being limited mostly to the muscles of the face and 
jaws, back of the neck and upper part of the trunk. Being less violent 
in its nature or in its course, the patient does not become exhausted to a 
fatal degree until the end of three, four and even six weeks. Cases of 
that duration are, however, very rare. 

A. "ftomical Changes. — in the large majority of cases in which post- 
n ortem examinations have been made, no lesions of structure visible to 



772 TETANUS. 

the unassisted eye have been detected in the spinal cord or brain, which 
could be considered as constituting an essential part of the tetanic dis- 
ease. A few of those who have had opportunity to make post-mortem 
examinations and have carried these examinations to a microscopic mi- 
nuteness, have found traces of sclerosis in some portions of the spinal cord 
and medulla oblongata. This has led them to regard the disease as 
essentially inflammatory in its nature, and akin to other affections involv- 
ing sclerosis or hypertrophy of the connective tissue of the cord, with 
wasting and impairment of the nerve cells. And it is probable that in 
many of the cases of traumatic tetanus in which the disease runs a pro- 
tracted course, minute examination would show some degree of the 
structural changes which are included in the word sclerosis, in the spinal 
cord. 

These changes, however, are undoubtedly the result of the continuance 
of the disease through several days. The absence of any other charac- 
teristic structural changes in the cerebro-spinal nervous centers leads to 
the supposition that tetanus, like some of the neuralgic conditions, is 
dependent essentially upon the development of an exaggerated or morbid 
degree of the elementary susceptibility of the nerve tissue; in other 
words, the alteration of the properties inherent in the nerve matter, 
rather than any appreciable alteration in the arrangement of atoms con- 
stituting the structure. In reference to the etiology of tetanus, the 
cases met with in practice are divisible into three classes. 

Causes. — The first are such as have been styled idiopathic tetanus and 
have usually been attributed to the effects of cold and damp air. But if 
it be true that they are caused by exposure to cold and damp air, it is 
proper to presume that the checking of eliminations causes retention in 
the blood of such elements as prove directly irritative, or capable of 
exalting the properties of the nerve matter of the cord, and consequently 
inducing tetanic contraction of the muscles to which the spinal nerves are 
distributed. Another class of cases much larger than that just alluded 
to are called traumatic, because they are traceable, more or less directly, 
to injuries or to the effects of surgical operations. Wounds of a pene- 
trating and lacerating character are much more liable to give rise to teta- 
nus than the incised or cleanly cut wounds. Many cases have originated 
from very trifling, penetrating wounds. The insertion of a needle or pin 
into the palm of the hand or bottom of the foot and sometimes in other 
portions of the surface have been sufficient to act as exciting causes of 
the disease. But much more frequently the disease is caused by such 
injuries as the penetration of a nail into the bottom of the foot by step- 
ping upon it or upon any sharp substance, whether metal or wood. 
But any lacerating or penetrating wound or the performance of any surgi- 
cal operation by which nerves or their sheaths are injured, may, in the 
progress of the case, transmit such an influence to the spinal centers as to 
develop tetanic rigidity of the muscles and all the phenomena and results 
ascribed to tetanus. How wounds or injuries produce the morbid action 
which we see in these cases is not easy to explain. Whether it is wound-) 
ing of nerves at the point of injury causing inflammation in the nervej 
matter and the transmission of the irritative influence to the spinal center, 
or whether in all such cases there is generated in the wound some poison- i 
ous or septic material that is transmitted along the nerve matter to the 
central portion, or through the blood like other septic poisons, is difficult 
to determine. The modus operandi by which traumatic tetanus is pro- 
duced, has never been satisfactorily explained. To say it is a reflex irri- 
tation in the spinal cord from some point of the periphery of the sentient 



prognosis. 773 

nerves is simply stating the fact rather than giving an explanation. The 
third variety of tetanus, that which occurs in young children or infants, 
is called trismus nascentium. It is usually manifested during the first 
two weeks after birth, sometimes in two or three days. In some coun- 
tries tetanus in young children is of frequent occurrence. Such is the 
case in I. -eland and the Hebrides islands. It is most apt to occur in the 
infants that are born in the over-crowded tenement houses or in the midst 
of bad sanitary conditions. Although met with occasionally, it certainly is 
not of frequent occurrence in our own country, and especially in this city. 
For in a busy, general practice of many years here, with a due propor- 
tion of attendance upon both mothers and their infants, I have met with 
no cases, except two or three, to which I have been called in consultation 
occurring in the practice of others. Some writers have attributed the oc- 
currence of tetanus in infants to the condition of the umbilicus while heal- 
ing, after the separation of the cord, in the same manner as they refer the 
disease occurring in the adult during the progress of wounds or injuries 
of various kinds. But the disease has shown itself in some infants after 
the wound left from severing the cord had entirely healed, and conse- 
quently couid have had no possible influence in producing it. One 
writer has attributed the occurrence of tetanus in infants to the continu- 
ance of the pressure of the occipital bone upon the posterior part of the 
brain. During severe and protracted labor with average pressure upon 
the child's head, there is always a pressing in of the occipital bone, while 
the parietal juts beyond or overlaps it. And if no care is taken to keep 
the child upon its side and it is allowed to rest the back of the head upon 
the arm of the nurse or on the pillow, when lying, this depression some- 
times does not become restored during the next day or two after birth, 
but remains and produces an injurious effect upon the functions of the 
brain. I have known several instances of this kind where the effect was 
such as to produce a constant peevish restlessness; a ravenous desire for 
nursing as if it felt an unusual appetite, and yet the grow;h of the child 
by nutrition, generally appears to be entirely suspended. Some instances 
of t; .is kind I have known to continue for three months after birth. The 
discharges from the bowels were consrantly more frequent than natural 
and very variable in color, with rapid emaciation and very little tendency 
to sleep in any part of the twenty-four hours. 

And yet, when the depressed condition of the occipital bone was de- 
tected, the child placed so as to rest the head upon the parietal pro- 
tuberances, leaving the occipital and frontal regions entirely free from 
pressure, a few weeks have sufficed to cause the occipital bone to resume 
its position on a level with the bones it joins, the patient soon became en- 
tirely free from the previous bad symptoms, and regained rapidly its ordi- 
nary flesh and strength. I have seen this in such a number of cases, that 
I have deemed it desirable to mention it here, if for no other purpose to 
put you upon your guard while in attendance upon mothers and their new- 
born babies. Observations in reference to the condition of the head in 
very young children should never be neglected. The symptoms of tetanus 
in infants are the same in all respects as in the adult, except that the rigid- 
ity or continuous contraction of the muscles is not as severe, while the 
paroxysms of a temporary character are of more frequent occurrence than 
in the adult. It almost always runs a protracted course of moderate 
severity, but ends fatally in a very large proportion of all the cases. A 
few cases of recovery are on record, but the tendency of the disease is 
very generally to a fatal termination. 

Prognosis. — This same remark, however, may be made in regard to all 



774 TETANUS. 

the varieties of tetanus — idiopathic, traumatic and infantile — it being one 
of the most severe, painful, and fatal affections which you will have to 
treat. 

Treatment. — As might be expected, in the management of a disease so 
generally tending to progress unfavorably until reaching a fatal result, a 
great variety of remedies have been tried from time to time, but without 
a satisfactory degree of success. At an early period, opiates were used 
freely, and in some instances in very large doses. And at the present 
time there are many who recommend as remedies of the greatest degree of 
efficiency, opium and the alcoholic class of anaesthetics. Some give from 
six to twelve centigrammes (gr. i to ii) of opium or its equivalent of mor- 
phine, every hour during the uay, and increase it at night, and from fifteen to 
thirty cubic centimeters (fl.fss to |i) of brandy between each of the doses of 
the opiate. In some instances during the same period of time, injections 
containing hydrate of chloral either alone or combined with belladonna 
have been used as enemas, and more or less chloroform inhaled for tem- 
porary relief from the more violent spasmodic action, thereby subjecting 
the patient to the strong influences of full doses of opium, chloral, and 
chloroform at the same time. At an early period after I entered upon 
practice, the dependence was placed largely upon opium, and patients 
were given such quantities, that in a day or two the pain, with tetanic 
contractions, ceased, the muscular system relaxed, and the patients passed 
into a profound sleep. In such cases there was great danger that the 
quantity of the opium which had accumulated in the system would render 
the sleep one of profound stupor with contracted pupils and speedy death. 
I must caution you to strictly guard against giving patients, in any form 
of disease, opiates, and at the same time other anodynes, and anaesthet- 
ics in different modes, rendering it almost impossible for \ou to estimate 
correctly the amount of influence you are to get from such combination 
of narcotics and anaesthetics in any given time. If the doses are fre- 
quently repeated it is impossible for the s}^stem to eliminate these drugs 
as fast as they are given. For instance, when opium is given in doses 
of six or twelve centigrammes (gr. i or ii) every hour, if at the end of 
twenty-four or thirty-six hours the tetanic rigidity begins to relax and 
the pains cease, it is evident that a very large part of the opium taken 
is still in the system, and may develop not only sleep but a dangerous 
degree of narcotism. In many such cases the patients have died coma- 
tose — not from the disease but from the effects of the remedies us^d. 

And in this affection, as in delirium tremens, there was a period many 
years since, in which death often resulted after the disease had subsided 
from the direct effects of the large doses of narcotics used for its cure. 
If it be true that tetanus depends primarily upon the establishment of a 
peculiar and extreme morbid sensitiveness in certain tracts of the spinal 
cord, connected through the nerves with the muscles of voluntary motion, 
the leading indication for treatment is to overcome that morbid condition 
of the cord without seriously interfering with the continuance of other 
important functions of the economy. From the knowledge that we pos- 
sess of the modus operandi of drugs, we should expect to accomplish 
more in removing the pathological conditions constituting tetanus by 
such agents as physostigma or calabar bean, ergotin, cannabis indica, 
chloral hydrate, conium and hyosciamus, than from any other remedies 
now known. All these agents appear to be capable of diminishing more 
or less directly the morbid excitability of the cerebro-spinal nerve 
centers. 

In scanning the medical literature of the present time there can be 



TKEATMENT. //O 

found a varied amount of evidence in favor of the curative effects of the 
physostigma, cannabis indica and chloral. Dr. Watson, of Glasgow, Dr. 
Fraser, of Edinburgh, and some others, have reported a considerable number 
of recoveries from the efficient use of the physostigma, its use having been 
commenced early and pushed to as large a degree as would seem to be 
safe. Of the eighteen cases reported by Dr. Watson as treated by phy- 
sostigma, ten recovered. Dr. W. M. Kane, of Philadelphia, treated a case 
successfully, in which the ordinary tincture of physostigma was given in 
doses of from four to twelve cubic centimeters (fl. 3 i to 3 iii) every few 
hours for several days. A well-marked case that came under my own ob- 
servation of traumatic tetanus arising from the penetration of a nail into 
the bottom of the foot, although not recovering, was relieved to a very 
marked degree for several days by the use of the physostigma, cannabis 
indica and hydrate of chloral in combination. The effects of the remedies 
were such as to lead me to the confident conclusion that if they had been 
commenced in the beginning of the disease, it would have been controlled 
permanently. But the first four days in the progress of the case were 
passed under treatment entirely inefficient, and the patient had conse- 
quently become considerably exhausted before being put upon the 
remedies that I have just mentioned. Perhaps the whole manage- 
ment of ordinary cases of tetanus may be summed up in the direc- 
tion to keep the room of the patient darkened, as perfectly free 
from noise and excitement as possible, the smallest number of at- 
tendants that will be adequate to administer to his wants efficiently, 
giving milk, beef tea or other liquid nourishment in small quantities 
while the patient can swallow them, and after a while add the use of 
nutritive enemas, and the prompt, efficient and persistent use of such 
doses as will be safe, of one or more of the remedies I have just men- 
tioned. If they are used separately, my confidence would be first iii the 
physostigma, next in ergotin and cannabis indica, and third in chloral. 
But I know of no reason why we should not give more than one of these 
remedies at the same time, especially a combination of physostigma and 
ergotin, or the cannabis indica and chloral. The extreme exacerbations 
may be palliated while carrying on this treatment by the inhalation, 
temporarily, of sufficient chloroform to mitigate the violence of the 
spasms. Some form of application may be made to the spine. The ap- 
plication of bags filled with ice water has been recommended by some, 
keeping them in contact with the whole length of the spinal column. 
There are, however, those who with equal confidence advise the applica- 
tion of bags filled with water, as hot as can be borne. While still others 
apply early thorough counter irritation, blisters and sinapisms. I should 
expect more benefit by cupping and the application of bags filled with water 
as warm as can be comfortably borne, kept steadily in contact with the whole 
length of the spine during the first two days, and if the disease was per- 
sistent, the application of blisters pretty extensively. 

And where the cuticle had been raised, alter the blister was removed, 
two or three centigrammes (gr. -J- to |-) of morphia might be sprinkled upon 
the raw surface two or three times in the twenty-four hours, and it would 
be likely to be taken up in sufficient quantity to produce a moderate de- 
gree of diminution in the sensibility of the sentient nerves of the part, 
and thereby help some in alleviating the sufferings of the patient. There 
are some cases of tetanus that are idiopathic in which there is evidently 
more or less of the malarious influence. Patients have been subjected to 
that influence, which is prevalent in the atmosphere where they live, and 
the symptoms of the tetanic disease are aggravated at certain times each 



776 HYDROPHOBIA. 

twenty-four hours sufficient to indicate clearly that this agent has pro- 
duced some effect upon the patient. Where this is the case, while the 
same remedies may be given with all due degree of activity, moderately 
full doses of quinine should be added two or three times in the twenty-four 
hours. For if it can not be well taken by the mouth, it can be used hypoder- 
mically, or introduced by enemas through the rectum. In the treatment 
of tetanus in young infants, trismus nascentium, chloral has gained more 
reputation than any other one remedy. It should be taken in fair doses 
and increased gradually till either the disease yields or the patient dies. 
Some of this class of cases have been treated successfully with quinine. 
In all cases, whether those in which the disease has its appearance in 
youno- infants, or in traumatic cases, the extent of the wound should be 
carefully examined, and every source of irritation as far as practicable 
removed from it. If there is any evidence of the generation of septic 
influences, the thorough use locally of antiseptics should not be omitted. 
In a few instances where the disease has originated from injuries to 
sentient nerves in one of the extremities, amputation has been resorted 
to with a very few reported recoveries. 



LECTURE LXXIX. 



Hydrophobia— Its Causes, Clinical History, Pathology, Diagnosis, Prognosis and Treatment. 

GENTLEMEN : Hydrophobia is a disease not of frequent occurre?ice 
but one of the most fatal with which the physician has to deal. It is 
supposed to originate from a specific poison, usually derived from wounds 
inflicted by some of the lower animals laboring under the disease. How- 
ever, there is not wanting evidence strongly indicating the possibility of 
the disease originating without any such communication or inoculation. 
The lower animals chiefly subject to the disease are the dog, cat and other 
varieties of the same general class of the animal kingdom. As the dog, 
cat and other domestic animals have access to houses, fend are more sub- 
ject to attacks of this disease than any other species, they are the chief 
sources from which individuals become inoculated. The popular impres- 
sion is that the disease is more apt to originate in dogs during the warm 
season of the year ; hence the hottest part of summer has received the 
appellation of " dog days" And in some countries and municipalities 
even up to the present time, laws are enacted and enforced requiring dogs 
co be either shut up or muzzled during the heat of summer, founded en- 
tirely upon the supposition that their liability to become affected with hy- 
drophobia is connected with the prevalence of high heat. Th.'s, however, 
is erroneous, as has been shown conclusively by statistical investigation. 
A paper read to the American Medical Association a few years since pre- 
sented facts and statistics, clearly proving that rabies or hydrophobia was 
quite as prevalent among the domestic animals, particularly the dog, 
during the winter as the summer; consequently there is just as much ne- 
cessity of muzzling these animals or preventing their running at large at 
one season of the year as at another. 

When an individual has been bitten by an animal laboring under the 
disease, and in such a manner as to allow the introduction of any of the 



CAUSES. /// 

saliva into the wound, there is great danger tint inoculation will ensue, 
and an attack o( the disease at some subsequent period will follow. I say 
when the wound is inflicted in such a way that more or less of the saliva 
of the rabid animal enters the wound, because theYe is sufficient evidence 
to justify the assertion that the poison is conveyed chiefly in the sal'va. 
Inoculation with the blood of a rabid animal would probably produce 
similar results. But in the infliction of wounds by biting it is not merely 
the wound that causes the mischief, but it is caused by inoculation with 
the poison, which appears to impregnate the saliva of the animal. Conse- 
quently, when a bite is made through one or more thicknesses of clothing, 
there is a strong probability that the saliva will be wiped from the teeth 
of the animal by the clothing, and although penetrating deep enough to 
inflict a wound in the flesh, it will often happen that no saliva finds its way 
into the wound. In such instances thi chances are strongly in favor of 
the individual escaping any subsequent^harm. And as such are the cir- 
cumstances under which a large proportion of the bites take place, it can 
readily be seen why it happens that a large proportion of those who are 
actually bitten by rabid animals do not suffer attacks of the disease. So 
far as statistics have been gathered it would appear that on an average not 
more than one in six or seven of those bitten ever become affected with 
the disease, which is probably owing to the circumstances connected with 
the manner of the bite, as I have just explained. The escape of so large 
a proportion opens a wide field for deception in regard to the use of pre- 
ventive measures. It is natural to assume that the remedies which are 
applied to the wound and the mode of treatment adopted are the causes of 
preventing the subsequent occurrence of the disease, when in fact there 
may have been no inoculation with the poison. Where inoculation does 
take place the wound generally heals without any apparent difficulty, and 
the individual bitten remains apparently well, unless the mind is disturbed 
by anxiety and apprehension on the supposition that there is danger, for a 
period averaging from one to three months. In some instances, however, 
the incubation may be not more than two weeks, in others it may extend 
to six or twelve months, or if we are to credit the cases that are reported, 
it may remain dormant for two or three vcars, and then develop all the 
phenomena and results of genuine hydrophobia. I must confess, however, 
that it is a little difficult to conceive how a poison that has remained 
dormant so long a period should again assume an activity sufficient to pro- 
duce so violent a disease. 

It is more probable that in such cases, if a'l the facts could be known, 
either the disease originated spontaneously, independent entirely of the 
long-previous bite, or that a subsequent inoculation hai taken place and 
escaped record. That the disease may and does originate in some rare 
instances without definite inoculation, I think we are justified in believ- 
ing, although such occurrence may be very rare. A case came under my 
own observation in the wards of Mercy Hospital a few years since, in 
which no evidence could be found either within the recollection of the 
patient or any of his friends and acquaintances, that he had been bitten 
by a dog or any other domestic animal. No trace of injury could be 
found upon his person, and during the initial symptoms no particular 
locality afforded tenderness, which would suggest the possibility of a 
previous bite having been inflicted. Yet the case presented every symp- 
tom of typical hydrophobia, and proceeded as usual to a fatal termination. 
This w T as in the person of a man in the early period of adult life, whose 
business was that of a railroad engineer, but who a few weeks previous to 
his attack had been but little occupied in his business, and had pursued a 



778 HYDROPHOBIA. 

rather intemperate course of life, indulging in frequenting dancing parties 
and places of amusement till lat'e hours of the night, and of course subject 
to excessive excitement during the three or four weeks previous to his 
attack. 

Symptoms. — The symptoms of hydrophobia in most subjects usually 
commence with the appearance of unusual mental anxiety and depression, 
coupled with a peculiar nervous excitability. The countenance is ex- 
pressive both of anxiety and despondency. There is but little disposition 
to converse, little or no tendency to sleep, the mind is easily agitated and 
quickly provoked to ill temper. These phenomena usually are followed 
in from twelve to twenty-four, or at the longest forty-eight hours, by the 
addition of a feeling of constriction in the oesophagus and larynx, soon 
increasing to that of decided spasmodic action. 

The choking causes the patient to make attempts to swallow with ina- 
bility to do so, and the gasping for breath may be coupled with intense 
momentary mental excitement. The pulse now begins to be more fre- 
quent than natural and a little elevation of temperature. These phenom- 
ena soon assume the form of distinct paroxysms of spasmodic disturbance, 
particularly in the muscles concerned in respiration and deglutition. And 
these spasmodic movements are excited by almost every trifling occurrence . 
that may take place. An attempt to drink any kind of fluid will provoke 
them to such an extent as to threaten strangulation or arrest of breathing. 
Medicines may be directly refused, and the patient may push away food 
and drink as though repugnant, when the real difficulty is the distress 
that is occasioned by the spasmodic action provoked by the attempt to 
take it. Any attempt to converse, any sudden noise, movements of the 
body or footsteps in the room, will very generally provoke more or less of 
this spasmodic action of the muscles of the chest, neck and throat. And 
even where every source of annoyance is avoided, the room kept darkened 
and as still as it is possible, the paroxysms of spasmodic action, though not 
so frequent, will occur usually every five, ten or fifteen minutes, and pro- 
duce great excitement in the patient's mind from a sense of suffocation and 
apprehension of choking, leading sometimes to sudden and violent exer- 
tion. After the first two days have passed, in most cases, the paroxysms 
are accompanied by some delirium. The gasping for breath and struggles 
of the patient will sometimes in the midst of a paroxysm cause such irreg- 
ular breathing as to produce frothy saliva from the month and occasionally 
sudden closing of the jaws, which may catch folds of the inside of the 
cheek or edges of the tongue and inflict wounds upon them, as in other in- 
stances of violent spasmodic action. In the popular mind these struggles 
and this sudden closure of the jaws and delirious condition of the patient, 
are construed into efforts at biting. Sometimes the irregular respiratory 
movements occasioned by the spasm cause a stertorous noise in the 
breathing, sometimes quite loud, which are also construed into resem- 
blances to the barking of a dog. B it the popular notion of patients la- 
boring under hydrophobia biting and barking, are mostly erroneous. They 
suffer the most intense distress during the exacerbations, and are some- 
times so delirious as to make extraordinary exertion to get out of bed, and 
when attendants restrain them, manifest a violence of temper as a part of 
their delirium, and not as a special manifestation of the disease. The 
strength of the patient fails rapidly in the progress of the disease ; and 
the difficulty of taking medicines without increasing the violent parox- 
ysms to which the patient is subjected often limit the means of adminis- 
tration to hypodermic injections, and inhalation of anaesthetic vapors al- 
most entirely. The patients become prostrated so rapidly that they usu- 



ANATOMICAL CHANGES. 779 

ally sink into a state of fatal exhaustion in from throe to eight days; the 

average duration of the disease being about five Jays. The disease is dis- 
tinguished from other spasmodic and cerebral affections mainly by the 
mental phenomena, accompanied by the peculiar paroxysms of spasmodic 
action limited in a large degree to the muscles concerned in the act of 
respiration and deglutition, together with inability to take anything, in 
the way of food or drink, without provoking paroxysms of much greater 
activity, and the consequent apparent repugnance, not to water alone, but 
to everything. Although the patients manifest intense desire for drink 
during the active progress of the disease, they are deterred, not by dread of 
water, but by the dread of the extreme distress and threatened suffocation 
that follows the attempt to take it. 

Anatomical Changes. — In nearly all the cases which have been re- 
corded embracing post mortem examinations, evidences of decided con- 
gestion or hyperaemia of the ve-sseis bordering upon actual inflammation, 
have been found in the upper part of the spinal cord, medulla oblongata, 
convolutions at the base of the brain, and in some cases extending more or 
less into the central ganglia of the cerebrum. The case to which I al- 
luded as occurring in the Mercy Hospital was examined after death and 
the medulla oblongata, crura cerebri, cerebellum and pyramidal bodies 
were most intensely injected with blood of a bright arterial hue. The in- 
jection of vessels, or congestion, extended along the lower part of the pos- 
terior lobes of the cerebrum, and also between the lower surfaces of the 
posterior lobes and the cerebellum. There was also increased fullness of 
the vessels as far anterior upon the base of the brain as the origin of the 
optic and pneumo-gastric nerves. The upper part of th3 cerebral hemi- 
spheres presented but little alteration from the natural condition; the in- 
terior of the brain also retained the normal degree of density and structural 
appearance, but when cut through below the corpus callosum nearer to 
the base of the brain, most of the vessels oozed blood in a way to indicate 
some degree of increased fullness. A very correct model of the medulla, 
upper part of the spinal cord, and whole base of this brain, is still open 
for your examination in the museum of the college. So far as post mortem 
appearances go, they would induce us to regard the medulla oblongata as 
the chief center of pathological change. And if we remember that the 
muscles of respiration and deglutition are more profoundly disturbed dur- 
ing the progress of the disease than any others we shall see that the symp- 
toms and post mortem appearances are in harmony with each other. Un- 
doubtedly, the specific poison which gives rise to the disease, when it 
originates from inoculation, spends the larger part of its disturbing influ- 
ence directly upon this great cerebro-spinal center of the nervous struct- 
ures. And it is the profound interference with the functions of respira- 
tion and deglutition, that so rapidly causes prostration and so certainly 
leads to a fatal result. 

Prognosis. — While there are on record several cases claiming to be gen- 
uine cases of hydrophobia derived from inoculation, or the bites of rabid 
animals, reported as cured, it must be acknowledged that the prognosis in 
this disease is extremely unfavorable. If the cases reported as recovering 
were genuine hydrophobia, still their number compared with the whole 
number of cases is so small that it would represent the disease as one of 
the most uniformly fatal that the physician is called upon to treat. 

Treatment. — From the remark I have just made you will infer that there 
are yet known no specific remedies for the cure of hydrophobia; and, in 
fact, there are none in which we can place very strong confidence, as to 
their ability even to modify materially its progress, except merely to mit- 



780 HYDROPHOBIA. 

igate the patient's suffering. The cases which have been reported cured 
have been subjected to various methods of treatment. One or two are 
claimed to have been cured by thorough, hot water baths; one or two by 
the use of curare; I think one is claimed to have recovered under the in- 
fluence of large doses of cannabis indica; one by chloral hydrate; and an- 
other is said to have recovered under the influence of apomorphia, used by 
hypodermic injection. I will not go so far as some writers have gone in 
asserting that ail these reported cases are fallacious, or that they were 
founded upon mistaken diagnosis, and that the disease treated was not 
real hydrophobia. I see no reason why cases may not be cured, provided 
the patient can be kept from a fatal degree of exhaustion until the modified 
or limited amount of congestion is relieved and the poison eliminated 
from the system. And if it be true, as I have previously suggested, that 
the disease may originate spontaneously, with the same form of congestion 
and local disturbance Of the cerebro-spinal centers, developing symptoms 
precisely the same in all respects, except the absence of the specific poison, 
there would be no reason why this idiopathic development of the disease 
might not yield under the influence of remedies calculated to restore the 
contractility of the smaller vessels and lessen the peculiar grade of irrita- 
bility involved in the disease. But while cases have been reported as 
cured under various remedies, I think eaeh and all of these remedies have 
been tried in other cases with the most heroic faithfulness by every mode 
of administration practicable, and yet have failed so uniformly as to leave 
us very little confidence in their efficacy. It would seem that in those 
cases derived from inoculation of poison from rabid animals there 
were three leading indications to be kept in view in the management of 
each case: First, to administer as efficiently as possible such antiseptic 
remedies as might be supposed to exert a neutralizing or destructive influ- 
ence upon the poison itself. Second, such as are calculated to overcome 
or counteract the extreme functional disturbances or spasmodic actions 
which threaten to suffocate or strangulate the patient. This would require 
the most efficient antispasmodics or nervous sedatives that we possess. 
The third indication, founded upon post mortem appearances, would lead 
us to use whatever remedies may be found practicable for lessening cere- 
bral fullness, or hyperemia of the vessels of the medulla and base of the 
brain. If it be supposed that the poison itself is essentially composed of 
organic germs, it could be met probably with no more efficient germicide 
than the bichloride of mercury in as active doses as the patient would bear 
without producing injurious results. This substance has been proven by 
several direct experimenters, especially Dr. Steinberg, of the army, and 
Dr. H. O. Marcy, of Boston, to be, by far, the most active asfent in de- 
stroying the vitality of all known forms of bacteria, micrococci and bacilli 
that we possess. But aside from this, it would also act as an alterative, 
using the phraseology of former times, in lessening the inflammatory action, 
and theie-ore would be somewhat calculated to fulfill the third indication 
we have mentioned as well as the first. The second indication, to allay 
spasmodic action by lessening the extreme morbid excitability or irregular 
nerve influence radiated from the medulla upon the muscles of respiration 
aid deglutition, a temporary resort may be had during the most violent 
paroxysms to anaesthetics by inhalation. Chloroform, ether, nitrate of 
amyl, using due caution in their administration, may be made greatly to 
mitigate the suffering of the patient, although these agents appear to exert 
no curative effect. In the same direction we might expect much from in- 
troducing in any practical way into the system efficient doses, either of 
caiuabis ind.ca physostigma, ergotin, or chloral hydrate. To attempt to 



PROPHYLAXIS. 781 

put patients into hot vapor baths, and still more into hot water baths, in- 
volves a degree of disturbance that usually aggravates the suffering and 
renders more frequent the violent spasms, and thereby tends to produce 
more harm than benefit. The intelligent selection of remedies aimed at 
the accomplishment of the three indications I have mentioned, and their 
judicious and persevering use according to the indications and principles 
which have been explained, will afford the patient the best chance of re- 
covery. The patient's room should be darkened and kept free as possible 
from every variety of annoyance or unnecessary disturbance, with efforts 
to sustain the patient with nourishment either by injections or by swallow- 
ing, if the latter act can possibly be performed. 

JProphyletxis. — In regard to a disease so uniformly fatal, and in which 
the cause is very generally known as consisting of a poison by the direct 
biting or infliction of a wound, the subject of prophylaxis becomes one of 
paramount importance. Almost the only safety the patient may be sup- 
posed to have, if introduction has certainly taken place, is based upon 
the success of measures that may be adopted to prevent the poison from 
developing in the system. The means of prevention may be divided into 
two classes: one having for its object the actual prevention of disease, 
by the destruction of the poison before it can be taken up by the 
vessels of the wound, and the other the prevention of the multiplication of 
the poison in the system after it may have been absorbed. The first object, 
that of preventing the poison from being absorbed, is regarded by many 
as the only reliable method, and the means consist of immediate excision 
of the part bitten in toto. Where the opportunity for doing this is 
afforded almost immediately after the infliction of the wound, and it is cer- 
tainly known that the wound is that of a rabid animal, and has been in- 
flicted directly upon the naked part and not through the clothing, it would 
be justifiable to excise it, cutting out the flesh so completely as to be 
pretty sure of removing all the poison. After such excision, cauterize 
the surface that is left and wash it thoroughly with some antiseptic wash. 
But it is not often, or at least it is only in a minority of the cases, that 
the surgeon is so near at hand, or the parties so self-possessed in their in- 
telligence, that immediate excision is available. Where this is not availa- 
ble most writers encourage the direct application of caustics. For this 
purpose strong nitric acid, nitrate of silver and various other caustics, 
such as undilute carbolic acid, have been recommended and extensively 
used. Where the wound has penetrated too deeply to allow complete 
excision with the knife, caustics must be made to penetrate as deeply as 
the wound itself. Another means of destroying the poison before it is 
taken up is by the application of efficient antiseptic solutions. Pretty 
strong solutions of carbolic acid, the sulphite or hyposulphite of sodium or 
a solution of the permanganate of potassium, and still more a solution of 
the bichloride of mercury may be made, not only directly to the surface 
of the wound, but by saturating fibers of lint and crowding them as near 
to the bottom of the wound as possible. 

After the wound has been thoroughly wet, lint may be saturated with a 
solution of either of the substances that I have named, and allowed to re- 
main over the wound constantly, the wetting being renewed several times 
a day, thereby rendering it probable that the solution used would be ab- 
sorbed through the same vessels freely that were most likely to have taken 
up the poison, if any had really entered the vascular system. But the 
efficacy, you will readily see, of any of these means, whether excision, 
cauterization or saturating the wound with antiseptics, depends entirely 
upon the question whether they have been made to reach the poison or to 



782 HYDROPHOBIA. 

intercept it before it has entered the circulation of the blood. After 
having entered the circulation, it can not be claimed that any of these 
agents are reliable. According to my observations, not more than one in 
ten of all the bites that are inflicted by dogs or animals that are supposed 
to be rabid are brought under the eye of any person prepared to apply 
any of these remedies efficiently in less than from one to ten hours from 
the time of the infliction of the bite. And you all know that the shortest 
of the periods named, i. e., one hour, is sufficient for any active poison to 
be taken more or less into the vessels, when in contact with the surface of 
an open wound. Consequently, in much the larger per centage of cases 
it must be acknowledged that the poison has probably passed beyond the 
reach of local treatment. This must not deter us from adopting local 
treatment as a possible means of destroying the poison before it has en- 
tered the circulation. So far as remedies are concerned, I should hold it 
to be a duty to apply some form of local treatment in every case presented, 
if no longer time than ten, twelve or twenty-four hours had elapsed from the 
time of the infliction of the wound. As to the relative value of the different 
modes of local treatment, I am not prepared to make a positive statement. 
The great preponderance of advice is to excise or cauterize or both. 
But for the last twenty years I have done neither, but have contented 
myself with the thorough saturation of the wound, as soon as the bites 
have been brought to my notice, with solutions of known strength, either 
of the bichloride of mercury or of a combination of carbolic acid and the 
hyposulphite of sodium. When the latter remedies are to be used, I 
make a solution containing at least twenty per cent, of the carbolic acid 
and thirty per cent, of the hyposulphite of sodium; and first introduce 
this solution as deeply into the wound as possible, and subsequently keep 
lint constantly wet with the solution laid directly over the part, re- 
newing it often enough to keep it moist constantly for two or three 
days. At the same time, from the very first knowledge of the case, I have 
uniformly ordered a solution of the hyposulphite of sodium, with tincture 
of belladonna to be administered internally. I give the hyposulphite 
of sodium in doses of six decigrammes (gr. x) with the same number of 
minims of the tincture of belladonna the first forty-eight hours at intervals 
of once in two or three hours, and subsequently Continue them regularly 
three times a day for at least four weeks or during the greater part of the 
first month after the infliction of the bite. I say, this has been my 
uniform treatment of all wounds that have come under my observation, 
suspected of having been inflicted by rabid animals. I have taken some 
pains to learn the results in as many of the cases as possible, and there 
has not yet occurred a single instance in which hydrophobia has ensued in 
any of the parties that have been brought under my observation and thus 
treated, although one or more cases of hydrophobia occur in this city and 
result fatally almost every year. 

It does not follow, however, from these facts, that any one of the cases 
would have had hydrophobia if they had not been treated at all; for a very 
large proportion of all the cases of wounds or bites that men, women and 
children receive from dogs and cats, whether belonging to their house- 
holds or in the streets, that they suspect may be rabid, are cases in which 
the animal had nothing of the disease suspected. It is to be presumed 
that occasionally one is rabid. But one difficulty in the way of carrying 
out an investigation concerning the condition of the suspected animal, so 
as to determine whether the bites that you are called upon to treat are 
inflicted by rabid animals or not, results from the almost universal prac- 
tice of immediately killing the animal. A dog is encountered in the 



SUN- STROKE. 783 

street looking tired, haggard, acting cross, snaps at parties who encounter 
him, soon attracts attention and in consequence of being- followed up or 
me Idled with, becomes still more cross, endeavors to bite his way, and 
inflicts wounds upon one or more parties. The animal is immediately 

dispatched and put out of the way. No person competent to judge has 
him, and being dead, there is no mode of determining positively 
whether lie was laboring under any disease of the nature of hydrophobia 
or not. This, however, is the history of nine out of ten of all the cases 
that create alarm in the community. If we make allowance for these, and 
then also make some allowance for the failure in many of the cases of 
really rabid animals to convey the poison through the clothes which the 
teeth penetrate before they enter the flesh, we shall see that of all those 
bitten only a small number are really inoculated. And therefore it is 
quite probable that any person occupying a wide field of observation, 
would have a number of these wounds, which are suspected to have been 
inflicted by rabid animals presented to him and subjected to treatment of 
some kind, in which there would have been no bad results developed 
if there had been no treatment at all. And yet no one, as a physician, 
would be justified in assuming that every case coming to him was 
harmless, and therefore refuse to take proper precautious. On the 
contrary, the possibility of the introduction of so deadly a poison should 
cause us as intelligently as possible to neutralize it from without, by 
agencies most certain to destroy it before it reaches the interior, and with 
equal promptness to introduce into the blood, as freely as will be borne 
without injury to the patient, such agents as are supposed to be most ef- 
ficient for destroying all existing germs, and of preventing further devel- 
opment from any that may have been introduced. The agent that is used 
internally should be continued not less than from four to six weeks. Another 
benefit resulting from this treatment is the influence it exerts on the 
mind of the patient. The simple fact that something is being done to 
destroy the action of the supposed poison has a powerful influence in 
quieting the fears of the patient and his friends, and in giving them con- 
fidence, hope and cheerfulness, which is exceedingly desirable, from the 
well known fact that the opposite condition of mind, namely, fright, ap- 
prehension, dread, foreboding of terrible consequence 3 , have a powerful 
influence in encouraging the development of the very disease that is 
dreaded. 



LECTURE LXXX. 



Sun-Stroke— Its Varieties, Causes, Clinical History, Anatomical Changes. Prognosis, Diagnosis 
and Treatment. 

GEXTLEMEX: Under the terms, sun-stroke, heat*stroke, coup de sohil. 
have been grouped a class of cases of suddenly developed disease 
dependent more or less for their immediate causation upon high tempera- 
ture. It is not essential that the high t-mperature be produced by the 
sun, or that the sun's rays be admitted directly upon the subject taken 
sick. A study of the various cases described as belonging to this class 
will resolve them into three groups, having some differences which are 



784 SUN STROKE. 

important to recognize, especially with a view of properly adjusting treat- 
ment. Of those which have been produced by the more direct, intense 
action of the heat of the sun, there are a few cases which appear to be 
simply acute attacks of meningitis. They correspond in all respects with 
the most severe grade of inflammation of the meninges of the brain, as ] 
have already fully described to you when speaking of the local inflamma- 
tions, and consequently these cases need not be further considered here. 
The more numerous class of cases included under the general designation 
of heat-stroke, occur generally under the direct action of the sun, or in a 
very high temperature of the air, and are characterized by all the symp- 
toms of sudden and severe congestion of the vessels of the brain, and the 
membranes covering it. 

Symptoms. — In these cases the patient, while exposed to high tempera- 
ture, begins to feel a sense of confusion and pressure in the head, distinct 
buzzing or rushing in the ears, dimness of sight, more or less intense pain 
in the head, and in a few moments staggers and then falls to the ground 
or to the floor in a state of entire unconsciousness. Sometimes as they 
fall a shudder like a slight electric shock passes through the muscular 
system, after which the muscles more generally are relaxed and the limbs 
quiet, but the face becomes deeply suffused with redness, soon assuming 
more of a purplish or cyanosed hue; the breathing becomes hurried, irreg- 
ular and sometimes stertorous; the pupils of the &ye are slightly dilated, 
though sometimes varying or vacillating from contraction to dilatation; 
the vessels of the conjunctiva are unnaturally full; the pulse usually fre- 
quent and somewhat variable, sometimes bounding and full, at other times 
small or contracted, but pretty uniformly frequent, and the heart's action 
partaking of a similar variable character, sometimes throbbing or pulsat- 
ing violently, and then again more feeble and irregular as to the 
rate of frequency. In the most severe class of cases the pulse grows more 
rapid and more easily compressed, the lips and face more deeply purple, 
the breathing more and more obstructed or stertorous, and in from fifteen 
minutes to two or three hours death takes place without any return of 
consciousness, though sometimes preceded by a general convulsion, but 
in a larger number by entire muscular relaxation. Cases of less severity 
may linger, from three to twelve or eighteen hours, and then terminate 
fatally apparently by suspension of the cerebral function, or by cessation 
of the heart's action after a few paroxysms of violent beating. In cases 
of a little less severity the symptoms may be of the same character, suffi- 
ciently severe to bring on complete unconsciousness, a flushed, turgid con- 
dition of the vessels of the face, head and neck, continuing for Ave or six 
hours, when signs of improvement begin. These are first noticeable in 
the surface becoming less purple, the pulse slower, more steady, and the 
breathing less stertorous, with a deeper, fuller inflation of the lungs. This 
improvement continues gradually until in eighteen or twenty- four hours 
the patient has recovered his consciousness; the pulse and respiration re- 
turned more nearly to their natural standard, and although extremely ex- 
hausted and feeble, convalesence has ensued. One symptom mentioned 
as characterizing these cases, and a very important one, is the rapid devel* 
opment of a high temperature. In the severer class of cases progress- 
ing toward a fatal result, the temperature rises so rapidly that in the 
axilla the thermometer will often range from 42° to 43° 0. (103° to 
110° F.) Less severe cases will show a rancre of temperature from 
40° to 42° C. (104° to 108° F.) during all the first twenty to thirty-six 
hours, if the patient lives that length of time. But as the symptoms of 
recovery and improvement show themselves, the temperature falls pretty 
rapidly till it returns to the natural standard. 



HEAT EXHAUSTION. 785 

Anatomical Changes. — The anatomical changes which are found, as 
might be expected from the rapidity with which death approaches, and 
the brief time that the patient is sick, are not of a structural character; yet 
many changes in the condition of the circulation are noticeable in all these 
cases, and also in the quality or condition of the blood. The sinuses and 
veins within the cranium are usuall}' strongly congested or turgid with 
blood; the right side of the heart is in the same condition with a consider- 
able amount of congestion and engorgement in the lungs; while the left 
side of the heart is usually empty and contracted; the blood itself is very 
much diminished in the coagulability of its fibrine, indeed, not infrequent- 
ly in an entirely iluid condition, of a dark hue, and many of the corpuscles 
crenated or puckered at the edges. 

Heat Exhaustion. — The remaining group of cases which have been 
classed under the general head of sun-stroke, and which really are the 
most numerous class of cases met with in practice, occur not so much from 
direct exposure to the rays of the sun as from the exhaustion of continu- 
ous high temperature. The symptoms differ very decidedly from those 
last described. The class of persons that are most apt to be attacked with 
this variety of disease, which byway of distinction is called heat exhaustion* 
are those undergoing either excessive physical exercise in an unusually 
warm atmosphere, whether it be by day or night, in-doors or out, or those 
who have been addicted to the habitual use of alcoholic beverages. That 
the use of alcoholic drinks greatly predisposes to this form of disease 
has been proven by the observation of many medical men attached 
to armies, witnessing the results in soldiers upon a march under a high 
temperature. The uniform testimony of these observers is that the at- 
tacks are limited, not absolutely, but in a very great degree, to those who 
are addicted to the use of alcoholic drinks in some form. Dr. Bartholow, 
in his practice, speaks of his own observation when connected with a divis- 
ion of the army on a long march under high temperature, where for 
several days many succumbed to the influence of high heat, but they were 
limited almost entirely to those addicted to strong drink. A large pro- 
portion of all the cases that occur in our cities during the occasional waves 
of very high atmospheric heat in summer belong to this class. In 1868 a 
period of this high heat caused several hundred deaths from what was 
denominated sun-stroke or heat exhaustion in New York; several seasons in 
Saint Louis the number of deaths has been very large from the same 
cause. In this city our waves of high temperature are always modified in 
a material degiee by the cooling influence of the lake upon our border, 
and consequently these cases are far less numerous here than in the cities 
more nearly in the middle belt of the United States. Still in those sum- 
mers when there occur one or more extraordinary waves of high heat last- 
ing through several days in succession, it is not uncommon to meet with 
attacks of heat exhaustion well characterized, and occasionally reaching 
a fatal result. 

Symptoms. — The symptoms of this class of cases differ from those I 
have described as from direct heat upon the head, not so much in the 
feelings of the patient as in objective phenomena. For the patient com- 
plains sometimes for an hour or more of some sense of weakness or ex- 
haustion, dizziness or reeling in the head, noises in the ears, momentary 
dimness of vision, but especially a great sense of exhaustion; and yet, if 
a laboring man, he not infrequently persists in keeping at his work, and in 
from half an hour to two or three hours after the supervention of these feel- 
ings he begins to reel, the sight grows dim, his attempts to talk fail him and 
in a moment he falls prostrate and generally becomes entirely unconscious; 
50 



7Sf> HEAT EXHAUSTION. 

but instead of an appearance of congestion or fullness his face is pale, 
lips pale or livid, his surface cool, pulse quick, somewhat weak, very 
variable and irregular; heart's action generally weak, systolic movements 
short, quick and irregular; respiration imperfect, giving imperfect inflation 
of the lungs, and some stertor; the temperature hardly above normal, 
pupils of the eyes usually decidedly dilated, sometimes relaxation of the 
sphincters of the bladder and rectum, allowing apparently involuntary 
discharges, but more frequently only a scanty secretion of urine. In the 
more severe of these attacks the paleness of the surface, coolness of the 
extremities and feebleness of pulse increase with the supervention of a 
copious, cold, clammy sweat, irregular, sighing respiration, and in perhaps 
half an hour to an hour after the supervention of the attack, sudden death 
from cessation of the heart's action or syncope. But the great ma- 
jority of this class of cases if they are at all well taken care of will remain 
in a feeble, cool, unconscious condition for two or three hours, when they 
begin slowly to improve. The first noticeable improvement is in the color 
of the lip, in a slower and steadier condition of the pulse and a more natu- 
ral systolic action of the heart. Three or four hour.* later consciousness 
is restored and the patient, although feeble and feeling greatly exhausted, 
is nevertheless in a convalescing condition; and under proper manage- 
ment in regard to rest and nourishment, in a few days he will recover 
fully and resume his ordinary duties. In the cases of this class terminat- 
ing fatally, the post mortem appearances differ from the group just previ- 
ously described in there being much less evidence of congestion and full- 
ness of blood in the vessels of the brain, although there is usually consid- 
erable congestion of the venous part of the circulation in the lungs and 
fullness of the right cavities of the heart with dark, imper.ectly coagula- 
ble blood. The blood is more profoundly altered in its properties and in 
the condition of its corpuscles than in the cases previously mentioned. 
The difference in the pathology of this and the preceding group would 
seem to consist chiefly in the fact that in the first group, or those of heat 
fever, there is, with the deteriorative action of high temperature upon the 
quality of the blood, a primary and direct dilatation of the vessels of the 
brain and its membranes, and in the lungs perhaps, from vaso-motor paral- 
ysis, causing early and intense local congestion in these organs with 
diminished oxygenation and coagulability of the blood and consequent 
incapacity to maintain its natural impression upon the various tissues of 
the body; while in the second class of cases or those of heat exhaustion, 
the phenomena depend almost entirely upon the extreme alterations in 
the properties of the blood and in the impairment of the property which 
I have denominated vital affinity throughout the whole muscular struct- 
ures cf the body, without special local congestion or hypeiseinia in the 
brain. This absence of the local hyperemia or engorgement causes tiie 
coldness or low temperature in the second class of cases, and its presence 
explains the rapid accumulation of heat in the first class. 

Diagnosis. — But little difficulty can arise in forming a correct diagnosis 
in either variety of the cases I have been describing, where all the facts 
connected with the condition of the patient at the time of supervention of 
the attack can be known. The sudden supervention from a state of pre- 
viously comparative good health, to the intense engorgement or fullness 
of blood in the vessels of the head and neck, accompanied by the symp- 
toms that I have described as taking place under a high temperature, es- 
pecially under exposure more or less to the rays of the sun, can hardly 
leave a doubt upon the mind of the physician as to the nature and origin 
of the disease. But in cases, which may happen, where the patient is found 



DIAGNOSIS. 787 

perhaps upon the highway or in some place where he has been overtaken 
alone with no one to give any history of his previous condition or circum- 
stances, the question will immediately arise in regard to the first class of 
cases, those accompanied by congestion or heat fever, as to whether the 
patient is laboring under an attack of apoplexy, or the excessive stupor of 
intoxication from alcoholic beverages. From apoplexy, sun-stroke or heat 
fever may be generally distinguished by the character of the pulse, respir- 
ation and temperature. In apoplexy, the pulse is more uniformly slow, 
full and labored, with sustained cardiac force or impulse. The breathing 
is more constantly stertorous, with the well-known puff of the lips and 
cheeks in the act of respiration. The pupil of the eye at the beginning or 
earlv stage is more generally contracted. If it be in the advanced stage in 
apoplectic patients the pupils may be dilated, but they seldom correspond 
the one eye with the other, either in the degree of dilatation or in the axis 
of vision. Apoplexy rarely, if ever, affords anything like the high tem- 
perature that is found in the class of cases of heat fever. From profound 
intoxication, heat fever or sun-stroke is still more readily distinguished on 
comparing the symptoms critically, because the state of profound intoxi- 
cation, either from alcohol or opium, is accompanied by a reduced 
instead of increased temperature. Opium contracts the pupils strong- 
ly, while alcohol not only reduces the temperature instead of increas- 
ing fever heat, but it produces also an odor in the breath which can 
generally be detected, and the breathing is altogether steadier and slower; 
indeed, slower than in health, and much steadier and more uniform than 
that existing in an unconscious state from heat fever. If we compare 
these same diseases, i. e., profound stupor from alcohol or narcotics and 
apoplexy, with the cases of heat exhaustion, we may find more difficulty in 
some respects. But from apoplexy, heat exhaustion is distinguished, by 
the fact that the patient is pale, usually sweating profusely, and cold, 
with a very feeble pulse, symptoms which are in direct contrast with 
what are usually found in connection with apoplexy. But the phenomena 
of profound drunkenness or extreme alcoholic intoxication, and those of 
heat exhaustion, present many points of positive resemblance. In both, 
the temperature is low. In both, there may be moderate dilatation of 
the pupils, with a pulse soft, irregular and easily compressed. But in 
heat exhaustion, the pulse is usually much more rapid as well as feebler 
than it is in alcoholic intoxication. 

Usually the respiration in heat exhaustion is also more unsteady, pant- 
ing perhaps, an.l then interrupted, like one tired, than it is in a state of 
intoxication. The alcoholic odor in the breath generally characterizes 
intoxication and would be a suitable mark of distinction were it not for 
the fact that heat exhaustion very frequently attacks those who are 
already more or less under the influence of intoxicating drinks. Conse- 
quently you might nave a case of heat exhaustion with an alcoholic 
breath. But, however difficult it may be to distinguish them primarily in 
the height of their development, their progress leaves a sufficient margin 
of difference to enable trie diagnosis to be made in a few hours. Alco- 
holic stupor passes off gradually, all the symptoms approaching more and 
more toward the natural condition, till the individual appears to be only 
in a natural sleep, while heat exhaustion, if it be only a case of average 
severity, also in a few hours begins to diminish. The patient, however, 
arouses himself much earlier and exhibits much greater weakness, and 
yet much less of the unsteadiness of gait and peculiar mental traits that 
characterize an individual coming out from a condition of extreme intoxi- 
cation. 



788 HEAT EXHAUSTION. 

Prognosis. — When sun-stroke or active heat fever is the result of in- 
tense action of the sun's rays directly upon the head, there is great tend- 
ency to a fatal termination. In the group of cases, however, that we 
have denominated heat fever, while there is much danger to life in a 
large • proportion of the attacks, and a high ratio of deaths has resulted 
wherever these cases have become numerous, still they are not necessa- 
rily fatal. But the milder cases tend spontaneously to recovery, and 
many of the more severe cases, if taken in charge and treated judiciously 
from the beginning of the attack, recover. It must be admitted, how- 
ever, that this class of attacks involve much danger, and yield a pretty 
high ratio of mortality. Of those classes denominated heat exhaustion, a 
much more favorable prognosis may be given. Under any judicious 
management only a small ratio of mortality results in this class of cases. 
If the attack, however, is severe, complete insensibility supervenes rap- 
idly, and the pulse presents, from the first, great feebleness with irregu- 
larity of respiration and very much depression of mind. When the heart 
acts tumultuously for a few seconds, and then slow and feeble, it may be 
said that there is very great danger of a fatal result from syncope, or entire 
cessation of the heart's action. But of all the cases of less sudden and 
severe development there is reasonable prospect of recovery, unless the 
patient has been previously very much impaired in his vitality and recu- 
perative energies, by habits of intemperance or other exhausting influ- 
ences. 

Treatment. — As you will have inferred from the description both of the 
symptoms and anatomical changes, no one treatment can be mentioned 
that is suited to all the cases grouped under the heads of sun-stroke, heat 
fever and heat exhaustion. The different cases require to be very care- 
fully discriminated, that their treatment may be judiciously adjusted tc 
fulfill the indications of each case. Those denominated heat fever, in 
which there are rapidly developed symptoms of great fullness of the vessels 
of the head and face, and more or less accumulation of blood in the lungs, 
with a rapid rise of temperature, the indications are clearly for the appli- 
cation, promptly, of such measures as are calculated both to lessen the iull- 
ness of blood in the parts congested and to arrest the elevation of tem- 
perature. Consequently the prompt application of cold to the head and 
indeed to the whole surface, directing the nurse to wash the head and 
trunk of the patient over quickly but freely with cold water, sponging 
him subsequently with the same until the temperature begins to fall, con- 
stitutes one of the measures that can be made most available and efficient 
in the onset of the disease. In India, where these attacks are of frequent 
occurrence during some parts of a more than usually severe summer, the 
practice of applying douches of cold water to the patients and wrapping 
them subsequently in cold blankets with ice caps to the head is considered 
the most efficient practice, and of late years it has been much resorted to 
in some of the cities of our country where these cases are of frequent 
occurrence. In addition to these measures, dry cups between the snoul- 
ders and upon the back of the neck and the application of leeches to the 
temples may also be of some value. As soon as the patient can be made 
to swallow, remedies may be given to procure moderately free evacuations 
from the bowels and to encourage healthy and active secretion by the 
kidneys. But before the patient is conscious enough to readily take 
medicines internally, the bowels may be moved to some extent by ene- 
mas of warm water containing common salt or sulphate of magnesia in 
solution, and the circulation may be more or less influenced favorably by 
the use of digitalis. This remedy may be used hypodermically or it may 



TREATMENT. 789 

be used in the form of enemas into the rectum. After the temperature 
has boon reduced by the anti-pyretics externally and the use of digitalis, 
and sometimes cupping or leeching, if the symptoms improve, there can 
be but little done except to maintain the effects of the digitalis and the 
cold applications in a less energetic manner till the temperature falls to 
the natural standard and consciousness is restored. After its arrest, for 
.several days a mild, plain diet and the avoidance of mental and physical 
exercise will be sufficient in most cases to complete the recovery of the 
patient. In many instances, as I have remarked when speaking of the 
symptoms in the advanced stage of this class of cases, convalescence 
occurs. Where general convulsions make their appearance the most 
efficient means for relieving them are probably hypodermic injections of 
morphia, being cautious to use such doses as will not over-narcotize; or 
the inhalation of chloroform. 

Practitioners should be very cautious, however, how they use both these 
agents simultaneously, as has sometimes happened. I have known one 
or two instances where patients, not from heat stroke but from convul- 
sions from other causes, had taken full doses of chloral internally, at the 
same time had hypodermic injections of morphia, perhaps twice in suc- 
cession at short intervals, and as the convulsive movements did not 
cease readily, inhalations were added. The convulsions soon ceased, but 
with the cessation, profound stupor, rapidly failing pulse, and finally ces- 
sation of life followed. It may happen that in using pretty full medicinal 
doses of two or three different narcotics and anesthetics, the combined 
effect which comes to be develope 1 is much greater than has been esti- 
mated: And while they may overcome the morbid action for which they 
were given, the amount present in the system is sufficient to immediately 
produce a fatal result as the direct effect of the remedies themselves. 
Consequently, while it is admissible, either to parry convulsions in these 
cases by chloroform inhalation, or inhalation of other anaesthetics on the 
one hand, or by the judicious use of hypodermic injections of morphia, or 
morphia and atropia together, and to endeavor to accomplish something 
by enemas, using pretty full doses of chloral, you should be cautious 
not to use all these agents so rapidly one after the other that the effects 
accumulate in the system sufficient to develop a greater influence than 
had been intended. In the treatment of the second class of cases, or 
those which we have denominated heat exhaustion, where the surface is 
pale and cool, skin relaxed, circulation irregular and feeble, there are, of 
course, no indications for the use of the cold douche, or the external ap- 
plication of cold in any form. Neither is there any indication for deple- 
tion in any direction. The patient should be put entirely at rest in as 
cool fresh air as possible; warm applications applied to the head, perhaps 
warm bottles and flasks of warm water along the spine, and such reme- 
dies given internally as are calculated to improve the tone or contractility 
of the muscular structures, especially of the heart, and thereby counteract 
the tendency to impairment in the quality of the blood. In the uncon- 
sciousness of the patients and difficulty of their swallowing, remedial 
measures are limited largely to such remedies as may be used in hypo- 
dermic injections and enemas. Perhaps as good a combination as could 
be used for an enema consists often cubic centimeters (fl. 3iiss)of the fluid 
extract of valerian, two cubic centimeters of the tincture of digitalis and 
one cubic centimeter of the tincture of opium in sixty cubic centimeters 
of water about milk warm. An enema thus composed passed into the 
rectum gently and the parts supported as the syringe is withdrawn 
for a few minutes, will frequently be retained, the greater part of it 



700 DELICTUM TREMENS. 

absorbed, and the effects of valerian and digitalis on the circulate n 
are as favorable as can be induced by any other remedies. Such an enema 
may be repeated at intervals of three or four hours, during the first 
twenty-four hours in the progress of the case. Usually during that time 
the patient will have so far progressed in his recovery as to require littie 
else than simple nourishment and rest to complete his recovery. If the 
enema can not be retained in the rectum sufficient to be absorbed, the 
digitalis may be introduced hypodermically. In the same manner you 
can also introduce moderate doses of the sulphate of quinia, or sulphate ol 
cinchonidia for additional tonic effect. Most writers recommend the lib- 
eral use of alcoholic remedies in these cases, advising brandy or whisky 
to be giv T en by enemas, and when the patient can swallow to be taken in- 
ternally. My own experience has led me to the conclusion that if the 
patient had rest in good air, aided by the enemas that I have indicated, 
whenever he is capable of swallowing brandy or whisky, he is equally ca- 
pable of taking enough milk, beef tea or any other suitable nourishment, 
and for stimulants, tea and coffee, or their active principles, theine and 
caffeine, which are much more efficient and valuable than any kind of al- 
coholic remedies, and will yield a larger ratio of ultimate recoveries. It 
is a little curious to contemplate a process of reasoning by which it is in- 
ferred that the very agents that are most efficient of all others to predis- 
pose to and favor attacks of heat exhaustion should be so generally re- 
sorted to, and recommended as remedies in the treatment of the disease. 
But it only illustrates that apparently fixed and almost irresistible habit 
of resorting to alcoholic agents for every conceivable condition tint pre- 
sents an element of supposed weakness. Of course if the patient recovers 
after using any of that class of remedies, it is taken for granted that they 
aided in his recovery, notwithstanding the experience of those who with- 
hold them, gives a greater ratio of recoveries than were obtained under 
their use. 



LECTUKE LXXXI. 

Del'rium Tremens (Mania-Potu)— Its Causes, Clinical History, Anatomical Changes, Diagnosis 
Prognosis and Treatment. 

GENTLEMEN: We next invite your attention to a class of cases of 
disease which have usually been included under the names of delirium- 
Iremens, or mania-potu. As the name would indicate, at least the second 
name mentioned, the disease to which I allude arises chieflv from the ha- 
bitual and excessive use of alcoholic beverages. A very similar condition of 
the system, however, may be induced by the use of opiates and other narcot- 
ics and excitants. But practically they are of very rare occurrence, except as 
the result of the use of alcoholic drinks. The greater part of the cases by far 
are met with in those persons who are addicted to the use of the stronger 
drinks or distilled spirits, such as whisky, brandy, gin and rum, although 
the disease may be produced by the use of fermented drinks alone; yet 
such is seldom the case, for the simple reason that the quantity of alco- 
hol in the fermented drinks is so small as to require a very large amount 
of the liquids to produce the peculiar effect upon the brain and nervous 
system which constitutes delirium tremens. The disease is most general- 



SYMPTOMS. 791 

ly the result of the continued and excessive use of the stronger alcoholic 
beverages through a period of from one to four weeks, and at the same 
time the use of but a very limited amount of ordinary nourishment. You 
are all aware that as an ordinary rule, the individual who commences 
what is known as a period of dissipation or of almost continuous intoxica- 
tion, soon loses his appetite or relish for food, while his period of excessive 
drinking continues. Whether it be one, two, three or four weeks, he seldom 
takes a sufficient amount of ordinary wholesome food once a day. The re- 
sult is that his blood becomes impoverished of nutritive elements, derived 
from the daily supply of food, and becomes surcharged with the products 
of disintegration and waste that are retained in it from the effect of the al- 
cohol in diminishing the elimination of waste ingredients through the 
lungs, or taking up of oxygen in the opposite direction into the blood. 
This impoverishment of nutritive materials, coincident with a steady in- 
crease of the effete constituents, interferes directly with the play of vital 
affinity and molecular changes in the processes of nutrition and disintegra- 
tion. Sooner or later this places all the functions, and especially the func- 
tions of the cerebro-spinal nervous system, in a condition in which it can no 
longer perform its natural office. The pulse becomes generally soft, quick 
and irregular, skin cool, face pale, muscular system tremulous and un- 
steady, mind excited and apprehensive, little or no disposition to sleep; 
and after the commencement of these symptoms in from twenty-four to 
forty-eight hours the tremulousness is much increased, the pulse has be- 
come still more disturbed, lips bluish, face rather haggard and anxious, 
and the mind decidedly beginning to lose its power of self-control, and 
to be filled with images and hallucinations; noises are heard that are im- 
aginary, startling visions generally of unsightly and unpleasant objects 
appear on every side, and these so rapidly increase that the patient be- 
comes entirely delirious, or at least incoherent, and has no disposition 
to sleep. Frightful objects now appear to the patient in any and every 
corner of the room and on the bed, sometimes in the bed, keeping him 
in frantic efforts to get away or drive the snakes and demons away, 
until after three or four days and nights he arrives at a stage of extreme 
exhaustion; yet still sleepless, trembling, agitated in almost every muscle, 
v ith extremely quick action of the heart, thready and excited pulse, cold, 
extremities, sometimes frequent discharges from the bowels, and occa- 
sionally vomiting with scantiness of urine, and unless relief is obtained, 
in this class of cases, death from exhaustion supervenes, more generally at 
the end of the first or second week. While some cases thus terminate 
fatally, the great majority of them, if placed under any judicious manage- 
ment, will proceed to the development of all the phenomena I have indi- 
cated m a characteristic degree, and after five or six days the excitement 
begins to abate, the patient catches now and then a little quiet slumber, 
takes mere nourishment, and from day to day the pulse becomes more 
steady, the mind less annoyed by hallucinations, sleep more natural, and 
at the end of nine, twelve or fourteen days convalesence is fully estab- 
lished. The patient, though weak and pale, soon recovers his usual ap- 
petite and feeling of health while at rest, but is not well able to return 
to work, requiring either much mental or physical exercise until more 
time has been had to restore the normal condition of nutrition. There 
are all degrees in the severity of the attacks of what are called delirium 
tremens y from that stage where the patient is simply sleepless, apprehen- 
sive, startled at every noise or footstep and occasionally troubled with 
hallucinations of vision or sight, up to that extreme degree of develop- 
ment which furnishes perhaps the most violent and severe form of tempo- 



792 DELIRIUM TREMENS. 

rary mental derangement known, a form in which the patient makes 
the utmost exertion to escape, taking two or three persons to keep him in 
bed and prevent him from doing himself or others harm. Some of these 
cases in the active stage present the most frightful picture of terror, es- 
pecially at night, that can be imagined. Sometimes the protracted par- 
oxysm terminates in fatal exhaustion before the end of a week. But 
more frequently the excitement gradually subsides untii the case ends in 
recovery. There are two classes of cases of delirum tremens. One class 
consists of patients who are attacked after they have suspended the use 
of alcoholic drinks, and the popular idea is that their delirium comes from 
stopping their drink too suddenly. The other class is composed of pa- 
tients in whom the delirium is manifested while they are still taking their 
full supply of alcoholic drinks. In the first class the symptoms of deliri- 
um of a characteristic type may come on in from twenty-four to forty- 
eight hours after the alcoholic drink is stopped. But more generally the 
disease develops in from one to two weeks or the patient escapes an at- 
tack altogether. As I have just remarked, the popular idea is, that the 
delirium is caused by stopping the drink too suddenly. I am by no 
means satisfied, however, that this is true. On the contrary, in ail 
cases of this kind that have come under my observation the system hnd 
become so disordered or the stomach so irritable as to prevent them from 
taking more of either food or drink; and consequently they had no power 
to replace the exhausted nutritive elements of the blood and tissues in 
time to prevent the development of the characteristic functional disturb- 
ance of the brain. The de.irium came not because they stopped drinking 
altogether, but because they failed to stop before the organs of digestion 
and assimilation had become too much disordered to immediately re- 
sume their natural functions. Under my own observation, both in pri- 
vate practice and in along period of attendance upon a public hospital in 
which manv of these cases are admitted every year, I am sure that in as high 
a ratio as three out of four of all the cases I have seen, the delirium has 
supervened during the time the drinking was being actively continued. 
The patients have passed frequently into a state of delirium in its full de- 
velopment, while they were receiving a full supply of drink, and were 
taking it several times in a day. There is, however, little or no difference 
in the symptoms or course of the disease, whether it has supervened after 
drinking has been abandoned, or while it is being continued; I think the 
general experience of all has been that the delirium supervening during 
the progress of drinking is more likely to be persistent and dangerous than 
where it supervenes in a few days after the intoxicant has been suspended. 
As the degree of severity differs widely in different cases of both classes, 
so the duration also differs much. In somn instances of the milder type 
it will continue only three or four days and nights, when in others it may 
continue as many weeks. More generally the course of the disease is to 
run through its stages and terminate in from one to two weeks. Under 
judicious treatment very few cases continue beyond five or seven days. 

Anatomical Changes.— There are no phenomena revealed by post 
mortem examinations of those who die during the progress of delirium 
tremens that may be said to be characteristic, or the direct result of mor- 
bid action connected with the delirium. Almost all such cases show in- 
creased redness or vascularity of the mucous membrane of the stomach, 
sometimes of the duodenum also, with some degree of fullness of the 
vessels of the right side of the heart, moderate congestion in the capil- 
laries of the lungs and some degree of hyperemia or increased fullness of 
the vessels of the brain and its membranes. In some instances, however, 



PROGNOSIS. 793 

there is hardly more fullness of blood in the vessels of the brain and 
membranes than natural; but on examining the structure of the brain 
minutely, there has been found some evidence of changes in the nerve 
cells, indicating fatty defeneration or the appearance of fat granules and 
some degree of sclerosis or hypertrophy of the connective tissue, thereby- 
giving to the substance, when cut across and minutely examined, either 
increased hardness, which is the more common, or more rarely the 
opposite, called softening. These* changes, particularly those in the 
mucous membrane of the stomach, and that indicating structural 
degeneration in the nerve tissues of the brain or in the muscular struct- 
ure of the heart, where sometimes the same appearances of fatty 
degeneration exist as in the brain, are the result not of the delirium, nor 
do they occur during the progress of the delirium; but they are the 
effects of the alcohol upon the structures of the body during all the drink- 
ing habits of the individual, which have generally extended through many 
months or even years. The morbid condition of the brain and cerebro- 
spinal axis belonging especially to the disease denominated delirium 
tremens, is not one of visible structural change but of impaired nutrition, 
or impoverishment, coupled with a peculiar morbid susceptibility of the 
nerve structures, by which the functions of the brain are perverted, and 
the peculiar hallucinations and incoherences which constitute the essen- 
tial phenomena of delirium tremens are induced. 

Diagnosis. — But little need be said in regard to diagnosis, as it seldom 
happens that the history of these cases is not easily ascertained, and the 
peculiar character of the mental hallucinations, coupled with muscular 
tremors, following directly upon a course of alcoholic dissipation or of the 
excessive use of other intoxicants, leave very little room lor doubt as to 
the true nature of any given case. 

Prognosis. — The prognosis in delirium tremens, whenever it can be 
brought under judicious management in the early part of its progress, is 
favorable; yet some cases, especially when complicated with more or less 
active gastritis or duodenitis will terminate fatally under any treatment. 
They constitute, however, only a small percentage of the whole number, 
and aside from these and a still smaller number that have been met with, 
complicated with direct inflammation of the membranes of the brain, 
there is almost a uniform tendency to recovery. Probably forty-nine out 
of every fifty cases of ordinary delirium tremens not complicated with 
gastritis or meningitis would recover with no medication under simply 
careful nursing, rest and nourishment. Yet, such is the distressing nature 
of the delirium, the fear that it impresses upon the patient himself and 
upon his friends around him, that it becomes desirable, and indeed neces- 
sary in the great majority of cases, for the patient to be placed in the 
hands of a judicious physician, who may pursue some apparently definite 
and well-considered treatment. When they are not complicated as I 
have just said, the indications to be fulfilled in their treatment are very 
fully embraced in two words— rest and nourishment. So soon as the 
patient can be induced to commence even very brief periods of natural 
sleep and the processes of digestion and assimilation of food sufficient 
to begin the work of repairing tissues, just so soon he commences to en- 
ter upon his convalescence, and continuance of rest and nutrition will 
soon restore him to health. If possible, the management of a case of de- 
lirium tremens should embrace the service of a judicious and kind, yet 
courageous and patient nurse. This is of very great importance, as 
nothing is worse for a patient under the excitement of delirium tremens 
than having a dozen frightened individuals about him, endeavoring to 



794 DELIRIUM TREMENS. 

bold him by main force, and constantly arguing with him in an excited 
manner, to convince him that his hallucinations are only imaginary. 
All such management only makes him more excited, and aggravates 
the disorder in a very marked degree. One or two self-possessed, cool, 
deliberate and kind persons, who will take turns with each other and be 
with the patient continuously, and instead of arguing about the delu- 
sions of the patient simply proffer their services to aid and protect him 
from his supposed enemies, thereby quieting and encouraging him with as 
few words as possible, and when any positive restraint becomes nec- 
essary insist upon such only as is actually required to prevent him 
from self injury, and let even that much be done as far as possible under 
the pretext of protecting the patient from the snakes and hobgoblins that 
haunt him, and he will sooner sink down in weariness to rest, than by al- 
most any other influence that you can bring to bear. From medicines, in 
nearly all the cases only two influences are needed; the one quieting or seda- 
tive to the excited condition of the nervous system, and the other calculated 
to increase the steadiness and force of the heart's action. I know of no 
agents that fulfill these two requirements in a more reliable manner than 
suitable doses of the bromides and digitalis. The first act as pure seda- 
tives to nervous excitability, and the latter increases the force and lessens 
the frequency of the cardiac action, and also aids the quieting of the 
bromides. For many years pas: I have treated nearly all the cases of 
delirium tremens that have come under my care with these two remedies 
aided only occasionally by the addition of chloral hydrate at night. Gen- 
erally the chloral has been needed only during the first two or three 
nights. A very common prescription is bromide of potassium twenty-five 
grammes (3 vi), tincture of digitalis twenty cubic centimeters (fl. 3 v), 
simple elixir, sixty cubic centimeters (fl. 3 ii), and water sixty, (fl. ^ ii) of 
which I give four cubic centimeters, or a good-sized teaspoonful in a little 
additional water every two, three or four hours, according to the degree 
of excitement and mental agitation exhibited by the patient. In the early 
stage, when the patient does not become sufficiently quiet by these reme- 
dies to get some sleep, I add from ten to thirteen decigrammes (gr. xv to 
xx) of chloral about eight o'clock in the evening, and if the patient is not 
asleep by ten o'clock repeat the dose. I seldom give more than these two 
doses during the early part of each night for the first three nights, but 
continue the bromide and digitalis at the usual intervals, except not wak- 
ing the patient out of sleep to take medicine alter sleep is once induced. 
By pursuing such a course I have very seldom found a failure in steadily 
diminishing the phenomena of the disease, and after the first three or 
four days the chloral could be discontinued entirely, and the bromide and 
digitalis continued at intervals not oftener than once in four or six hour?. 
In some of the cases at the beginning of the treatment, the tongue is' 
found coated, the urine scanty, and there is a slight elevation of the tem- 
perature, indicating slight feverishness and general derangement of the 
secretions. With such, in addition to the treatment just described, I have 
given two or three alterative doses of calomel, lollowing it by a laxative, 
sufficient to move the bowels. These remedies usually remove the fever- 
ishness, correct the derangements of secretion, and more readily bring the 
stomach to a condition for tolerating and digesting such food as may be 
necessar} 1 -. Sometimes in the wildness ot delirium of the patients it is 
difficult to administer medicine with any regularity. They occasionally 
become suspicious of those around them, thinking they are trying to 
poison them with every dose that is g'ven. Consequently, the attendants 
are apt to become discouraged in their eftorts to administer either medi- 



TREATMENT. 795 

cine or food. In such cases great benefit may be obtained by Hypo- 
dermic injections oi* morphine either alone or tempered with atropine, 
sufficient to give the patient quiet, and often before the delirium is renewed 
you may succeed in the administration of other remedies and some 
nourishment. In some instances support can not be accomplished by in- 
jections, because it is found as difficult to use injections during the de- 
lirious condition as it is to give medicine by the mouth. I do not use 
opiates in the treatment of delirium tremens, except in those cases where, 
as I have just remarked, I find it impracticable to get them to take med- 
icine sufficiently regular by the mouth or rectum to get the effects needed. 
In such instances the temporary use of morphine becomes almost ab- 
solutely necessary. But great care should be exercised in using hypo- 
dermic injections of morphine lest the quantity thus used should produce 
too profound narcotism, more especially if given soon after full doses of 
chloral hydrate have been taken, so that when once quiet the patient gets 
the full toxic effect of both remedies and sinks into a sleep from which he 
never awakes. I have known several cases in wmich this result has act- 
ually been obtained much to the chagrin of the attending physician. 
Quiet, careful attention to ventilation, watchfulness, gentle nursing and 
the simple remedies I have just indicated, have been sufficient in my own 
hands for the last twenty years to conduct every case of delirium tremens 
to a safe recovery which has come under my control either in the hospital 
or out. There are many other remedies that may be used with advantage, 
but I know of no qualities that they possess superior to those I have in- 
dicated, and none more readily adjusted accurately to produce the effects 
needed. The patient must be just as intelligently supplied wuh proper 
nourishment and in proper quantities as with any of his remedial agents. 
If either is to be preferred the nourishment is the most important. It 
should be plain, easily digestible and readily absorbed, or convertible into 
elements of blood with but little active gastric digestion. For the larger 
proportion of these patients have but little normal gastric secretion and 
frequently considerable irritability of the gastric mucous membrane, so 
that nourishment should be given in very moderate quantities and usually 
in a liquid form until the patients begin to recover. Beef tea and other 
animal broths properly seasoned with salt, milk, lime water and milk, oat 
meal gruel and milk, rice and arrow root, are among the nutriments best 
adapted to these cases. As soon as they manifest a disposition to have 
other food they may be supplied with any ordinary plain food in moderate 
quantities as fast as the appetite demands it. They should be carefully 
guarded against too early returning to severe mental and muscular exercise; 
and especially should they be cautioned against ever returning to the use 
of alcoholic beverages; for every attack of delirium tremens evidently 
leaves the nervous system in some degree predisposed to another attack. 
Consequently, the patient more and more readily induces these attacks by 
repeating his potations, til 1 sooner or later, complications spring up in the 
form of gastritis and sometimes meningitis; or there supervenes in connec- 
tion with the drinking habit, fatty degeneration of the liver and perhaps 
sclerosis of the kidneys, and in the midst of the delirium sudden suppres- 
sion of urine inducing uraemic poisoning, convulsions and death. While 
on this subject of delirium from the use of intoxicating drinks, we might 
pass directly to the consideration of what has been denominated metho- 
mania or dypsomania; but, if such a form of disease exists, it is a species 
of mental derangement that will be more appropriately alluded to in the 
brief review I shall make of mental derangements in the next one or two 
lectures. 



796 MENTAL DERANGEMENT. 



LECTUEE LXXXII. 



Mental Derangements— Their Varieties, Causes, General Characteristics and Path ^logical Rela- 
tions. 

GENTLEMEN: Under the head of mental derangements, I shall not 
attempt to direct your attention to a full consideration of the various 
forms of insanity and impairment of mind which might be included 
under so general a designation. The subject of insanity in its relations 
to the individual, to the community and to the State, is so important and 
in some respects so different from other classes of disease that it has 
been very generally considered in separate treatises, and in modern times 
often entirely omitted from works on general practice. I have not 
thought it best, however, to pass the subject without a very brief consid- 
eration, aiming to make it such as would assist you, as general practition- 
ers, in recognizing the early stage of the different forms of insanity, and 
in comprehending the causes most likely to produce these disorders, that 
you might be prepared to render such patients a reasonable degree of 
assistance at that early period when medical attention and care has the 
best chance of success. A glance at medical literature will show that 
there are two prominent and distinct modes of viewing the subject of 
insanity. The one which was predominant until within the last few 
years, considers the subject from a psychological or philosophical stand- 
point almost exclusively, paying little attention to its connection with 
any disorder of the brain or nervous system. The other regards the men- 
tal derangements as in a great measure, if not wholly, the result of prior 
and coincident derangements of the physical organs through which 
mind is manifest, i. e., the brain and its appendages. It is probable 
that neither of these extreme views are correct, and yet there is a valu- 
able amount of truth in both. If you study the causes which are known 
to favor the development of mental derangements, you will readily 
observe that such causes are divisible into two classes; one class is 
addressed almost exclusively to the mind itself and may be said to be 
purely mental; the other acts with equal directness upon the physical 
organization, and consequently reaches derangements of the mind, neces- 
sarily through changes in the physical structure. You will remember 
that at the last lecture in alluding to the form of mental derangement 
called delirium tremens, which is caused almost exclusively by alcoholic 
drinks, that the physical agent, alcohol, makes its impression upon the 
structures of the brain and nervous system as well as upon the other 
organs of the body, and induces those changes in the nutritive functions 
that render the brain incapable of manifesting mental action in a coher- 
ent and natural manner, there can be no doubt. This would serve as an 
example of all that class of agents which act through the physical system 
in producing modifications in the properties or structure of the brain in 
such a way as to disorder the mind in its manifestations. On the other 
hand, persons who may be, as far as can be determined, in the most per- 
fect physical health, if subjected to causes that operate primarily and 
entirely upon the mental faculties, emotions and passions may, by persist- 
ence, develop derangements quite as certain and as serious in their char- 
acter as any causes that act more directly through impressions on the 
physical structures. It is only rarely that sudden and transient itnpres- 



CAUSES AND VARIETIES. 797 

sions upon the mmtal faculties and emotions, however intense they may 
be, have produced actual mental derangements, but it is those causes 
which act more or less intensely and persistently through considerable 
periods of time which are most likely to result in actual disorder to the 
mental faculties or in some form of insanity. Among the causes that 
act upon the mental faculties may be enumerated prominently, persistent 
cares and other depressing mental emotions long continued; intense 
mental application directed to some particular theory or problem, such as 
questions in theology or concerning the future existence, or such ques- 
tions in philosophy or metaphysics as have the power to concentrate some 
particular intellectual faculties so intensely as to interfere with regular 
sleep. The mind thus occupied with a special train of thought through 
many days and nights in succession is one of the more common causes of 
mental derangements. Those misfortunes consisting in loss of property, 
changes in domestic circumstances and disappointment of affections, when 
of siuh character as to cause loss of sleep and persistent dwelling upon 
the sime thing, are extremely liable to produce mental disorders, and are 
all of them addressed in their action to the mind itself. On the other 
hand not only the use of alcoholic drink*, but a variety of narcotics and 
anaeithetics and the existence of certain diseases, are capal le of producing 
such an influence on the brain as to disorder the mental manifestations. 
If the whole series of causes which favor the occurrence of mental dis- 
orders are examined closely and analytically, it will be found that a large 
proportion of those which aie addressed to the physical system, such as 
the narcotics, anaesthetics and other physical agents that are capable oi 
producing mental disorders, are characterized largely by impairment of the 
mental faculties rather than the establishment of permanent derange- 
ments of the intellect, although the latter often exist in the early stage in 
a prominent degree. After this stage is passed, however, if the phe- 
nomena do not cease entirely, they are more likely to be resolved into 
mental impairments tending toward imbecility or mental incapacity rather 
than into intellectual hallucinations or insanity proper. While the class 
of causes that are addressed to the mental faculties direct, are v^ry liable to 
produce the reverse result, namely, permanent hallucinations, illusions 
and reasoning from false premises, yet often maintaining much acuteness 
and quickness in their mental processes through a series of years. 

Varieties of Insanity. — The laws of England and of most of the S'ates 
of this country recognize two varieties of insanity, diagnostically called 
in the English law, dementia naturalis and dementia occidentalism cor- 
responding with the more common words idiocy and lunacy: dementia 
7baturalis meaning idiocy from birth, while dementia accidentalis includes 
all those cases that arise from any c luse after the mind has once been 
developed to activity. Those included under the second class, dementia 
accidentalis, or lunacy, may be further divided conveniently for purposes 
of diagnosis and recognition into two subdivisions, namely, mania and 
monomania. Cases of dementia naturalis or idiocy are also divisible 
into two subordinate classes which may be designated as dementia, and 
amentia. The first meaning impairment of mind, and the second, absence 
or complete loss of mind. Of course there :s no clear line of demirkation 
between these two subordinate divisions of the class of idiots, for they 
manifest all possible stages or grades of mental impairment, from that 
which falls only a little below the regular order of intellect, to that of com- 
plete absence of all manifestation of intelligence, constituting the amen- 
tia. The division of the second class into mania and monomania is founded 
upon the fact that there are many of the insane who manifest derange* 



798 MENTAL DERANGEMENTS. 

merits of the mental faculties generally, and are not able to control the 
mental processes, so as to reason correctly upon any subject. While there 
are many others who reason correctly, and as far as can be detected mani- 
fest all their mental operations in a natural manner in relation to all sub- 
jects and processes except perhaps a single topic on which they reason 
altogether incorrectly. The mind is said in such cases to be deranged 
upon one subject, or upon a particular class of subjects, while it is 
apparently unaffected in reference to all other subjects. You will mark 
taat this derangement is limited to some particular topic or class of 
topics and not limited to some particular faculty of the mind. This 
distinction has not always been kept in mind, and has led to the idea 
that the mind is capable of being deranged in one or two of its 
faculties and not in others. I have seen no specimens of that char- 
acter. But the mental derangement in regard to particular topics or 
particular subjects is of very common occurrence. The recognition of 
monomania, or derangement in relation to particular subjects has led more 
recently to the multiplication of forms of insanity to a degree which has 
seemed to me excessive. An effort has been made to show the existence 
of actual mental derangements as the cause of a large portion of the crim- 
inal practices existing in the community. Once recognizing the liability 
to derangements upon particular topics or subjects of thought, the at- 
tempt has been made to explain many atrocious criminal acts on the 
theory that the party committing those acts was insane on the subject relat- 
ing to them. For instance, the taking of property, or theft, has been recog- 
nized as a form of insanity called kleptomania. The disposition to reck- 
lessly set fire to buildings has been regarded as pyromania or as a form 
of insanity or insane impulse to commit arson. The exhibition of sudden 
and violent answer to the extent of committing* violent assaults and some- 
times murder, has been explained by alleging the existence of impulsive 
insanity. But if you adopt the reasoning of a considerable number of 
specialists of the present time in the department of psychological medicine 
and carry it to its logical results, you will be led to a position from which 
you will be wholly unable to maintain a line of distinction between crime 
proper and the freaks of insane impulses, and the special mental derange- 
ments upon particular subjects. And you will be compelled, as some have 
already done, to regard all crime as only the result of mental derange- 
ments, and further that such mental derangements are founded upon faulty 
physical organization. 

Of course such a position involves a denial of the justice of all punish- 
ment, as well as an obliteration of all distinctions between virtue and 
vice and between right and wrong. I make these allusions to prevalent 
tendencies simply to put you on your guard against being led by such 
reasoning to excesses, and not by any means to discourage close and care- 
ful investigation. Very many attempts have been made to give a defini- 
tion of insanity. A well known writer on mental philosophy, John 
Locke, defined insanity to be, reasoning correctly from false premises. 
The equally celebrated Dr. Abernethy of London, defined insanity to be 
the loss of the faculty of attention; while Dr. Connolly, having much ex- 
perience personally in the care of the insane, defined the disease to be, 
loss of the power of comparison and judgment. It requires but a moder- 
ate amount of familiarity with the insane to perceive that all these defini- 
tions are correct when applied to certain classes of the insane. You could 
hardly enter any asylum for this class of individuals containing a score 
of patients, without finding some of them who would reason as acutely as 
the best trained intellects are capable of doing, making all their deduc- 



SYMPTOMS. 7U ( J 

t'ons in strict harmony with the premises that they assume. But the 
premises themselves would be false. Consequently their deductions lead 
them into error, constituting their derangement. Others would be found 
among a similar number who would exactly correspond with Dr. 
Abernetby's definition, that is, loss of the power of attention. The mind 
would flit from topic to topic, notwithstanding all your efforts to fix their 
attention upon any one train of thought. Such individuals are common 
among those who are laboring: under mania or general insanity. 

Perhaps there is no more prominent symptom among them than 
this inability to fix the attention so as to hold any two trains 
of thought, or to keep the mind upon any two objects long enough 
to make a comparison or deduction. And equally easy is it to find 
in a limited number of the insane those who would correspond 
with the definition of Dr. Connolly, the loss of the power of com- 
parison and judgment. Indeed, this, when you analyze it, hardly differs 
from that of Dr. Abernethy. The loss of the power of comparison is 
nothing more nor less than the loss of the power to fix the' attention long 
enough upon two objects or two trains of thought to make a comparison. 
Of course, there can be no judgment or inference where the attention can 
not be fixed long enough to allow of a comparison. The comparison of 
different things and trains of thought is an essential requisite to the form- 
ing of a conclusion or judgment. Perhaps one of the most practical dis- 
tinctions to be made in the classification of mental derangements consists 
in drawing a line between those persons who are insane and those whose 
mental unsoundness consists directly in impairment in one or more of the 
mental faculties, which would cause them to be properly called weak or 
incapable, but in the operation of whose mind there is no apparent 
illusion, false impression or hallucination, and consequently not any 
drawing of erroneous conclusions, or what is diagnostically called 
delusions, but simply impairment in the readiness of mental action. Such 
cases exhibit slowness of thought and of speech, difficulty apparently for 
the mind to continue a train of thought, as exhibited frequently by losing 
it in the midst of a sentence and being unable to finish it. Such patients 
constitute a class that may be properly styled incapacitated or unsound 
in mind, but not technically insane. The other class would consist of ail 
those whom I would call, technically and properly, mentally deranged or 
insane; not simply weakened in mental action, but the mental processes 
more or less actually turned out of their normal channels of operation. 
And I think all without exception belonging to this class are, when the 
mental disorder has become well established, affected with certain men- 
tal phenomena, which may be ranged under three heads, namely: 
illusions, hallucinations and delusions. By illusions I mean an erroneous 
conception of a real object. Perhaps one of the most common that you 
will meet with is the illusion that the individual who is insane is himself 
some person entirely different from his real character. It may be 
the illusion that he is a king, a popular officer, a beggar, or the maker 
of the universe, constituting an illusion in reference to the real object, 
but perverting the character of that object. Or it may be an illusion con- 
cerning objects not personal, but of a strictly material character discon- 
nected from the individual, as when the friends or individuals around or 
connected with the insane person are regarded by him as persons entirely 
different from what they really are; giving to each of them a name and 
character that is purely fictitious. The illusion may consist in the im- 
pression, fixed and indelible, that the composition of the body is entirely 
different from that which is natural. For instance, a lady of very high 



800 MENTAL DERANGEMENTS. 

rank in England, in former times, is reported to have labored for years 
under the illusion that her own body was made of glass, rendering her 
extremely reluctant to have any one approach her through fear that such 
contact might break her to pieces. Particular articles of furniture are 
liable to be invested with illusions of the same character. The sense of 
taste and hearing also, as well as sight may be the seat of similar illusions, 
as when sounds are construed entirely different from what they really are, 
and sweet substances are thought to be sour and sour sweet, or bitter 
palatable. By hallucinations are meant the conception in the mind of the 
insane of the presence or proximity of bodies or phenomena that have no 
real existence, as the hearing of noises and conversation where no such ex- 
ist. Hallucinations may equally reach the mind through the organs of vision 
and lead to the supposition that objects, animals, friends or other parties 
are present, and apparently to their conceptions really present before 
them, that have no existence, while delusions are the conclusions or judg- 
ments that the insane person forms from the influence of these illusions and 
hallucinations. Acting and thinking as though the hallucinati ns and 
illusions are real, the insane person is of course led to erroneous conclu- 
sions, and from erroneous conclusions to delusions and erroneous acts, 
not infrequently of the most injurious and dangerous character. There 
are almost all forms of these illusions and hallucinations of which you can 
conceive. And not infrequently they take the form of jealousy or the 
investing of certain parties with false attributes, perhaps investing their 
very best friends, members of their own families, with the qualities of an 
enemy, conspiring with others to invade the domestic circle, rob them of 
their property, or do them bodily injury. 

Of a similar illusory nature is that form of insanity which causes the 
husband to attribute to his wife want of fidelity, and to put a false con- 
struction upon almost every movement that she makes, or the wife the 
same in regard to the husband, to such a degree that the suspected party 
can not transact the most trivial business with other parties without almost 
every word and act being construed in a false light, or regarded as evi- 
dence of some criminal intention. These are usually classed under the 
general head of jealousy, yet they are all resolved either into illusions or 
hallucinations. But I said in the beginning that one of the leading ob- 
jects in alluding to this subject of insanity, was to call your attention to 
those symptoms and conditions which characterize the forming stage of 
insanity and their diagnostic value, that you might be the better pre- 
pared, not only to detect the existence of mental disorders early, but also 
by early and judicious treatment to arrest its progress and save the in- 
dividual from so great a calamity as the full development of mental 
disorder. And this leads me to a brief review of the symptoms and prog- 
ress of some of the chief forms of insanity from their incipient beginning 
to their full development. 

Symjitoms. — Perhaps one of the earliest and most important symptoms 
of the approach of insanity consists in a marked change in the individual 
from his ordinary or natural mode of thought and demeanor. A marked 
alteration in this respect is always worthy of notice. Among the very 
earliest symptoms are, with one class, the manifestation of self-conceit, or 
assumed importance or positiveness that is unnatural to them. Another 
class, instead of exhibiting self-conceit and arrogant assumptions, show a 
degree of despondency, distrust and indisposition to freedom of conversa- 
tion, or manifest a desire to remain silent to a degree quite unnatural and 
contrary to their usual habit. Perhaps a still larger class show their first 
manifestations by distrust or suspicion of some particular party or some 



SYMPTOMS. 801 

limited number of parties, or at times in reference to everybody, causing 
them to act every day as though making an effort to conceal their suspi- 
cions. Yet by a very moderate amount of intercourse their attempts at 
concealment fail, and they soon betray the distrust or suspicion which 
they evidently feel, and which is persistent with them from day to day, 
causing them to be apparently non-communicative and reluctant to speak 
of their plans, their movements, or anything that pertains to the object of 
their distrust. With all these changes from the natural condition of the 
individual as early traits, there is almost invariably an impairment of the 
ability to sleep. Their nights become disturbed and wakeful. If they 
retire as usual, they do not sleep. They are forced to get up much ear- 
lier in the morning, sometimes in the middle of the night. These changes 
from the natural condition, or tone of mind and feeling in any direction, 
maintained through many days or weeks in succession, should always 
lead to a careful consideration of the causes, and it will seldom fail to 
prove the precursor of some form of mental derangement. If to these 
slighter and more obscure alterations from the natural mental condition 
of the patient we add somewhat uniform wakefulness at night, sometimes 
a continuous pain in the head, and the manifestation of unusual despond- 
ency without adequate cause, or on the other hand, undue excitement, 
equally without adequate cause, with occasional expressions indicating a 
suspicious disposition, or an unusual interpretation of the acts of others, 
perhaps of intimate friends, it will show not only that mental derange- 
ment is approaching, but that it has already commenced. And if these 
deviations simply continue to increase from day to day, the reasoning 
faculties will soon so far loose their control that the illusions or false 
conceptions formed in the mind of the patient will inevitably betray him 
into the more open manifestation of insanity. The cases that have al- 
re&dy been alluded to, are those which commence slowly, and usually 
lead to what may be termed chronic forms of mental derangement. They 
may persist in their development till the mind becomes deranged upon 
all subjects, constituting general insanity. Or, the insane trains of 
thought may be confined to particular topics, and remain there throughout, 
the whole course of the disease, constituting partial insanity or monoma- 
nia. The disease may present a great variety of deviations. After the 
individual has been led into the first deviation from the natural train of 
thought he will very generally assume, and act upon the idea that some 
particular individuals or agents have caused that train of thought, and 
this will give character generally to all the subsequent insane develop- 
ments; the derangement of mind will be limited to these individuals or 
topics. It may take the direction of extreme depression, under the im- 
pression that they are lost; that the day of salvation or any future happi- 
ness for them has gone by; or it may take the opposite direction, that of 
being elated with the idea that they are already passed into the state of 
perpetual enjoyment, or that they are some high religious dignitary, dis- 
pensing happiness to others. Cases of the first kind are much more nu- 
merous than the latter, and constitute some of the most typical instances 
of insanity that we meet with. 

Another very frequent train of insane thought has reference to the 
character and actions of the patient's most intimate friends, and has for 
its basis, jealousy or suspicion. It may relate to property, the suspicion 
being that certain parties are in conspiracy to deprive them of their prop- 
erty. And in relation to that topic no amount of reasoning can correct 
their delusions, while upon all other subjects they will converse and act 
as rationally as other parties. The suspicion may fall upon some mem- 

51 



802 MENTAL DERANGEMENTS. 

ber of their own family, the husband suspecting the chastity or conduct 
of the wife, or the wife that of the husband not only in relation to fidel- 
ity to the marriage contract, but in relation to their being in conspiracy 
with other parties to put the patient out of existence. The suspicion not 
infrequently fastens itself upon their most intimate friends or family rela- 
tives. And under such circumstances often the first manifestation of 
their illusion is a refusal to eat under the suspicion generally that what 
is prepared for them has been poisoned. They will refuse to eat at 
first, often without acknowledging why. For the same reason they will 
often refuse to take medicine through fear of being poisoned by it. Often 
I they will remain awake the greater part of the night, watching for some 
anticipated movement against themselves by the parties they suspect. 



LECTUKE LXXXIII. 



Mental Derangements Continued— Clinical History, Diagnosis, Prognosis ani Treatment. 

GENTLEMEN: At the close of the preceding lecture I was direct- 
ing your attention to the various phases of insanity. There is hardly 
a topic that ordinarily occupies the human mind but what may become 
the subject of insane delusions, constituting what is denominated mono- 
mania or partial insanity, while on all other topics the individual retains 
his usual correctness of mental operations and maintains very good gen- 
eral health in many cases for years. If you choose to look through the 
special works upon insanity or the treatises upon medical jurisprudence, 
in the chapters devoted to insanity in its various forms and relations, you 
will find the details of many interesting cases of the various forms of 
monomania. As I said before, these forms do not always affect the 
reasoning or the intellectual faculties but are sometimes confined to the 
emotions and passions. And when thus confined they are capable of pro- 
ducing erratic and sometimes highly criminal acts, which are difficult for 
those who have not made the matter a subject of study to understand 
or excuse. The individual retains apparent appreciation of right and 
wrong and his power of reasoning as well as ever upon almost every topic, 
and yet is subject to certain impulses apparently beyond his control, of a 
criminal character. I allude now to those impulses which have been 
manifested to commit assaults upon other parties, as in the case of a sud- 
den impulse to destroy life or commit murder. This, however, is not 
always explainable upon a sudden impulse, but sometimes originates from 
an insane impression of having received a direct command from the deity, 
as when a father kills one or more of his children under a direct impres- 
sion that he is ordered to do it by the deity and can not help himself, or 
as in a case that occurred in this city only a few years since, where a father 
who had been deranged upon a general or religious theme and who had 
been properly adjudicated insane and confined in an asylum, was thought 
by the superintendent to have recovered and consequently was allowed to 
return to his home. Within a few days after his return, however, he de- 
liberately killed his wife in open day, under the fixed impression that he 
was commanded by the deity to sacrifice the dearest object of his affec- 
tions. And as that was his wife he deliberately proceeded before her 



SYMPTOMS. 803 

face to shoot her dead. That this was an insane act purely, there can be 
no doubt. Many cases have occurred of the destruction of wife, children 
or members of the family, under delusions operating upon the mind in a 
similar manner. 

We may explain sometimes possibly, the acts of criminals in commit- 
ting arson or murder, through the processes of mental derangement. But 
it requires very great care to distinguish between the actually insane in 
these cases of emotional or impulsive insanity, and those of true deliber- 
ate criminality. For such ditferences, however, I must refer you again to 
that portion of works on medical jurisprudence, which treat of the crim- 
inal relations of the insane. When insanity has approached in a slow, 
obscure manner as I have described, and has finally established either 
general derangement of the mental faculties, or a limited derangement 
having reference to particular topics and trains of thought, there is little 
tendency to any self-limit in the progress of the affection, particularly so 
long as the objects which are the subject of the insane thought are within 
sight or proximity of the patient. If they are separated entirely from such 
relations and placed at an early period under the control of strangers, as 
when removed to institutions especially for the care of the insane, a large 
proportion are capable of recovery. The proportion will be much larger 
than if left within the circle and in near contact with the individuals and 
circumstances under which the derangement first developed. Cases of 
general insanity often originate in a sudden and acute manner as I have 
already indicated, especially when the exciting causes are such as act 
with a high degree of intensity upon the mind. For instance, when 
the mind receives some violent shock, as in sudden loss of large amounts 
of property or of immediate relatives, or when they are placed in circum- 
stances where they are under great mental apprehension of some disease, 
or the approach of some sudden accident, striking terror; in all such, the 
intense mental impressions are capable of producing the most sudden and 
rapidly developed general derangement of the mind, so rapid sometimes 
that the individual passes almost immediately into a state of frenzy, with 
loss of all control over the intellectual faculties, constituting general acute 
mania. In such cases the symptoms are often very violent. The individ- 
ual exhibits a wild or excited expression of countenance, often manifest- 
ing the most violent outbursts of temper and emotion, ready in some in- 
stances to assault their best friends with the utmost violence, or, in their 
terror, to plunge themselves without the slightest hesitation from windows 
at any height above ground, where the fall would be immediate destruc- 
tion, and without any disposition to sleep for many days and nights in suc- 
cession. These are cases of acute general mania and yet amidst it all, 
you can generally trace certain hallucinations and illusions that are the 
basis of their derangement. 

Another form of acute general mania is that which attacks lying-in 
women and is called puerperal mania. The disease frequently develops 
within a few days after confinement, but in some cases not until several 
weeks have elapsed. The first indications of the approach of this form 
of disease are simply change in the individual's modes of expression and 
thought, saying things that are odd and unusual for them, refusing to 
take nourishment and unable to sleep at night. These symptoms usually 
progress so rapidly that in from one to three days the patients are found 
to be in a condition of general mental derangement. They are almost 
always suspicious of those immediately around them, so much so that it is 
extremely difficult to induce them to take sufficient nourishment through 
fear of being poisoned by their supposed enemies. In almost all cases of 



804 MENTAL DEBASEMENTS. 

acute general mania the patient becomes rapidly reduced by the refusal 
to take adequate nourishment, the want of sleep, and the constant mental 
excitement, as indicated by their becoming more pale, the pulse quicker, 
softer, more easily compressed, the extremities often cold, and in the 
most severe cases this exhaustion will continue to increase unless they 
are relieved by appropriate treatment until it reaches a fatal termination; 
sometimes in the course of one or two weeks, but more frequently not till 
the end of five or six weeks. While some cases will thus run through 
an acute course to a fatal result, far the larger number after the first two 
or three weeks become modified in the intensity of the mental derange- 
ment, so far that the patient catches now and then short periods of sleep, 
more nourishment is taken and the physical system is consequently sus- 
tained while the mental derangement goes on in what may be called a 
chronic form. In such cases after assuming the chronic form as well as 
in those that may be said to be chronic from the beginning, there is a tend- 
ency to ultimate atrophy and impairment of nutrition especially in cer- 
tain portions of the cerebral substance. Perhaps the parts most fre- 
quently involved where atrophy and wasting can be detected, or in the 
acute cases that terminate fatally at the early period where hypenemia 
and increased vascularity are most noticed, are in the central ganglia, 
especially the corpora striata optic thalami, and to some extent the gray 
matter upon the surface of the cerebral hemispheres. The parts least 
affected are the posterior portions of the cerebrum. In long continued, 
general insanity, there is in most instances a noticeable degree of atrophy 
of some portions of the cerebral substance, more particularly of the gray 
material, either of the convolutions upon the hemispheres or the ganglia 
at the center as I have already mentioned. This atrophy has sometimes 
extended through the medulla to the lateral gray matter of the spinal 
cord and become associated with general atrophy of the muscular system, 
constituting what I have already alluded to when speaking of the inflam- 
matory affections of that portion of the cord as the general atrophy of the 
insane. This brief outline of the premonitory symptoms and the more 
prominent phenomena accompanying the different degrees and stages of 
insanity, and the tendency of the disease either to assume the chronic 
form or to lead to such changes as may terminate early fatally, are suf- 
ficient to give you that degree of knowledge which every practitioner of 
medicine should possess. As I have before intimated a whole lecture 
could be readily taken up in describing the different phases of mania and 
monomania without exhausting the subject. 

Pathology. — I have just stated to you that where death takes place dur- 
ing the progress of acute mania, there is usually found more or less hy- 
peraemia or accumulation of blood in the vessels of the convolutions upon, 
the hemispheres of the brain, and in the corpora striata and other portions 
of gray matter at its base. The microscope reveals still further molecular 
disturbance in the structure of the parts where the most hyperemia exists, 
probably closely analogous to the ordinary changes that accompany in- 
flammatory action; and in those chronic cases that have been of long 
duration, the anatomical changes as previously remarked are those of 
atrophy or diminution of nerve structure, with perhaps some slight degree 
of sclerosis or hypertrophy of the connective tissue. And in very many 
cases where death has taken place by some accident during the progress 
of ordinary cases of insanity, both general and partial, a close scrutiny from 
dissections, and from microscopic examinations, have failed to detect any 
characteristic lesion in the nerve structure or any part of the nervous 
centers. And I am compelled to admit that many cases of insanity are 



PROGNOSIS. 805 

not explainable from any recognizable change or disease in the physical 
structures of the brain and parts with which the mind is associated. I 
do not mean that all insanity is unaccompanied b}^ these physical changes. 
I am well satisfied that there are many forms or cases of insanity that 
have their primary origin directly in the structural changes as the starting 
point of morbid action, but there are others in which the primary impres- 
sions are upon the faculties of the mind, and whatever changes take place 
in the physical structure of the brain are secondary, or the result of the 
persistent disturbance of function, and not primary as the cause of that 
disturbance. In other words we may have mental derangements from 
causes that influence mental action alone as the primary departure from 
the healthy standard independent of any prior structural lesion. I am 
aware that some of those occupying high positions and justly regarded as 
authorities, hold to the doctrine that there is no such thing as a diseased 
m nd, independent of morbid conditions of nerve structure. But certainly 
no facts derived from actual examinations, with all the modern appliances 
for making such examinations minute, have yet been developed sufficient 
to justify that conclusion. 

Prognosis. — The prognosis differs much in accordance with the kind of 
insanity and mental derangement that exists, and its mode of origin. A 
large proportion of acute cases are susceptible of being conducted to a 
reasonably early recovery. To this class belong those of puerperal mania, 
nearly all of which, under favorable circumstances and judicious manage- 
ment, ultimately recover. Perhaps not quite to so great an extent, and 
still sufficiently so to include a majority of cases, those arising from causes 
that are temporary or of short duration, however intense in their opera- 
tion at the time. The cases which are most likely to be persistent and 
to resist treatment are such as come on slowly from causes that act with 
only moderate degree of intensity, but persistently through long periods 
or" time. They consequently develop the mental derangements in the 
manner that I first described, so obscurely, that the attacks are hardlv 
noticeable until weeks and perhaps months have passed by, and where the 
c.iuses still exist, and the individual is left within the reach of their in- 
fluence. Another element which influences the prognosis is that of hered- 
itary predisposition. As a rule those cases of insanity that are induced 
by temporary causes without any previous hereditary predisposition on 
the part of the patient are much more likely to recover than where any 
strong family tendency or hereditary influence favors the development of 
the disease. The latter influence also tends greatly to induce relapses 
after recovery or partial recovery has occurred. Notwithstanding, it may 
be said as a general rule that the prognosis in any given case will be im- 
proved or made favorable, just in proportion as the patient can be taken 
under the most judicious management early in the progress of his disease, 
and separated as completely as possible from all association with the in- 
dividuals and circumstances under which the disease was developed. 
Consequently it is of very great importance that insanity be detected 
early, and that the most efficient and judicious steps be taken for counter- 
acting it by removal of the causes or the removal of the patient from their 
further influence, so far as it is possible to do. 

The timely administration of such remedies as may have influence in 
counteracting the early symptoms of the disease is also important. Each 
individual case must be treated upon its own merits. The almost con- 
stant tendency of the insane to refuse medicine and defeat all efforts 
at its administration at regular intervals while left under the control of 
friends or ordinary nurses, and the continued action of the causes that have 



806 MENTAL DERANGEMENTS. 

given rise to the disease, make it desirable to remove the patient to other 
places, and in association with entirely new parties, just as early as they 
possess the symptoms or give positive evidence of the existence of mental 
derangement, whether it be general or partial. And often after the men- 
tal symptoms that I have pointed out to you are recognized, if judicious 
measures are taken as far as possible without betraying to the patient the 
suspicion that mental derangement is approaching, and at the same time 
the closest and most careful attention be paid to the physical health of 
the patient, seeing that the digestive organs are kept in good order, the 
bowels regular, and if possible from six to seven hours of good sleep 
secured, the development of the disease will in many cases be arrested at 
its beginning and all the subsequent evils prevented. Usually the reme- 
dies most likely to act favorably by procuring sleep for this class of 
patients in the forming stages of mental derangements are not opiates; 
for while they will frequently produce the required amount of sleep, they 
so far tend to restrain secretions and impair appetite, that they lead to 
secondary conditions of the system that are more favorable for the further 
development of the mental derangement, than though the remedies had 
not been given at all. I have found no combination of remedies that in 
so many cases produce an amount of quiet natural sleep, with no second- 
ary ill effects, as that of the bromide of potassium, sodium or ammonium 
in connection with digitalis and hyoscyamus. These three remedies, giv- 
en either separately or conjoined in he same prescription, so that their 
effects shall be developed during the evening at such time as would be 
the natural hour for retiring to sleep, will usually produce a better effect 
than can be obtained from anything else. After the disease has made a 
fair beginning, and especially after the sleeplessness is fully developed, 
the mind positively suffering some derangement, it will often require 
larger doses than usual to produce the desired effect. But there is little 
danger in pushing these three remedies conjointly, sufficient to produce 
the desired effect, if the patient can be induced to take them, or if not 
they can sometimes be used by enema. In my hands they act much more 
favorably together than either of them alone. During the periods of high 
excitement, it may sometimes be desirable to combine chloral with the bro- 
mide, but my own observation in the use of chloral has led me to regard it 
as very liable to be irregular and often slow in developing its effects. I 
have repeatedly seen it given in full doses as early as seven or eight 
o'clock in the evening when its effects in inducing sleep did not follow 
until after midnight, and then the patient awakes in the morning dull, 
stupefied, and often remains more or less incoherent all the remainder of the 
day. Aside from the use of such remedies as are calculated to keep the 
evacuations from the bowels, and the action of the important secretory 
organs, like the kidneys and skin, free, it is not desirable to trouble the 
insane with frequent doses of medicine. Simply, either by diet, or by such 
remedies as will accomplish the purposes I have just named, and the use of 
those remedial agents that are most efficient in inducing quiet, natural 
sleep with the least tendency to leave secondary unpleasant effects, ad- 
ministered at the proper time in the evening, and leaving the patient dur- 
ing the day but little annoyed by anything except taking the necessary 
amount of nourishment, is a better plan than to pursue more active, con- 
tinuous medication. Equally necessary with the medical treatment is the 
adoption of the most judicious means for inducing the patient to take the 
necessary amount of nourishment. And this leads directly to another 
part of the management of the insane, which is of the utmost importance. 
This is what may be termed the mental or moral management. More will 



TREATMENT. 807 

depend upon this than all other circumstances combined. A mind that 
is disordered in such a way that the reasoning- faculties do not control 
the attention, the emotions, passions and trains of thought is not in a con- 
dition for argumentation. One of the most common, and most injurious 
influences that are brought to bear upon the insane, is the disposition on 
the part of their friends to be continually trying to convince them of the 
error of their thoughts and delusions, and consequently to keep them ex- 
cited by arguments till perhaps both patient and attendants become irri- 
tated by their mental contest. Any such conversation only aggravates the 
deranged condition of the patient, and adds to the certainty of prolonging 
the disease. All the attendants upon the insane should be rigidly required 
to avoid the least appearance of excitement and of a disposition to contra- 
dict and argue. The uniform tendency should be to soothe, encourage 
and kindly influence the mind of the patient in such a way as to gain his 
confidence by leading him to think you understand his wishes, and will 
aid him as far as possible. Even so far humor his impulses and insane 
trains of thought as may be necessary to gain his confidence, and make 
him think you are his protector. It is so difficult to get most members of 
the families interested in the insane to take such a course and assiduously 
avoid combating what appear to them as groundless fancies, that it con- 
stitutes one of the reasons why it is desirable as early as possible after 
insanity is fairly developed to remove the insane parties entirely from the 
care of their immediate friends. The same principle that I have laid down for 
the mental management of the insane by kindness and by seeking their 
confidence leads to the rule that you should avoid as long as possible the 
resort to physical force as a means of restraint. The straight jacket and 
the direct, positive restraint by any species of mechanical appliance of 
force should be resorted to only in the last extremity, and when no other 
mode will prevent the patient from a degree of violence directly danger- 
ous to their own existence or that of those around them. It is remarkable 
to what extent some persons of experience and natural tact will control 
the insane by mental management alone without the least appearance of 
restraint or controversy. Such management will do more to secure an 
early return to a sane condition of mind than all the other influences that 
can be brought to bear. 

As I have often spoken of the removal of the insane from the care of 
their friends, you will be ready to ask whether it is desirable, as a uniform 
rule, that they should be removed as early as possible after the insanity 
becomes clearly evident, to some institution or asylum expressly for their 
care. I answer, that such a removal to some kind of an asylum away 
from their friends, and the immediate circumstances under which their 
disease developed, is necessary and desirable, as early as it is possible to 
do so. But it is by no means a matter of indifference as to the kind of 
institution to which they are removed. Much good would result from 
careful discrimination in this respect. There are very many of the insane, 
who could be removed with benefit to private asylums, under the care of 
skillful superintendents and nurses, where there are only limited numbers 
of the insane under treatment, and consequently where it would appear to 
the patient much more like a home, than like a public institution, with its 
surroundings. There are some other forms of insanity, quite harmless, 
involving no tendency to violence, in which the individuals, if removed 
from their immediate surroundings simply to some other family or place, 
where their associations would be different, and where they would be un- 
der the immediate care of some person skilled in their management, 
would do better than in a private asylum. But there are many other in- 



808 MENTAL DERANGEMENTS. 

sane persons, especially those who are affected with general insanity, who 
will be better provided for in a public asylum, built expressly for the care 
of the insane, with all the necessary furniture and attendants for their pro- 
tection and care, and where every circumstance and surrounding imparts 
to them a kind of awe or restraint. There is not enough attention paid 
to the classification of the insane. As I have said, there are some who can 
be safely, and most successfully treated, on what has been in modern times 
termed the family or cottage plan, where they can have the aid of other 
members of the family, and be continually subject to the watchful eye of 
a judicious attendant. Others will be more properly accommodated in 
well regulated private asylums in which only a limited number of patients 
are received. There are some others, as I have just stated, who can be 
with more propriety assigned t*> public asylums, if they are provided with 
a sufficient number of attendants or nurses and under judicious supervis- 
ion. Perhaps, before leaving the subject of insanity, 1 should say a word 
or two in regard to that form of disease which has been denominated by 
some methomania, or mental derangement consisting in an uncontrolla- 
ble disposition to indulge in the use of intoxicating beverages. It is 
claimed by many at the present time that inebriety, or habitual indul- 
gence in the use of intoxicating drinks to an injurious extent, is a disease, 
rather than the result of vicious habits. There are others who place 
great importance upon what is termed the hereditary disposition to ine- 
briety. They teach that in a large portion of those who become habitual 
drunkards, either periodically or continuously, that such habit is the re- 
sult of a defect in their organizations derived more or less directly from 
hereditary influence, developed by the same habits in their ancestors. 
Of course the inference of such, is, that the inebriety being the result of 
physical conformations, or morbid conditions of the nervous system, it is 
to be treated as such. The fact that there are very many persons in the 
most civilized communities, who develop at an early period of adult life 
a remarkable disposition to indulge in the use of intoxicating drinks at 
certain periods of time, constituting what are known as periodical drunk- 
ards, is familiar to every one, and they constitute enigmas to most people. 
They will abstain entirely from the use of all intoxicating drinks, be ap- 
parently in good health, attentive to all their duties and industries every 
day, for from one to six months perhaps, and then without any visible 
cause go directly into the period of drinking, keep themselves in a state 
of daily intoxication, usually till their digestive organs become so de- 
ranged and irritated as to cause them to reject their drink, as well as their 
food, and thus compel them to desist. Others stop simply because their 
money is exhausted, and perhaps end in either threatened or actually de- 
veloped delirium tremens, or there are many, as explained, who, having 
nothing further to buy drink with, would be compelled to desist for a few 
days. In either case, having stopped until sober, they resume their 
ordinary diet, soon return quietly to their work, and are apparently as 
free from the disposition to drink again for a similar period as any other 
person in the community. These periods of dissipation or inebriety usu- 
ally increase slowly in frequency with each individual, so that parties who 
would have at first only one of them in a year, in process of time come to 
have what they call their drinking sprees every three, four or six weeks, 
till it completely destroys their ability to maintain their position in 
society, or to carry on their business successfully, and they consequent- 
ly become ruined, both in health and in their social and pecuniary 
relations. 

It is a mystery why an individual after frequently experiencing all the 



TREATMENT. 809 

evil effects of drinking, again and again, should be able to abstain rigidly 
and apparently without effort for months at the time, and yet persistently 
return at stated periods to the same practice and undergo the same evil 
effects. There is, no doubt, some obscure, but persistent morbid condi- 
tion of the central portions of the nervous system in these cases. When 
the habit has become fixed, such individuals should be provided for by 
proper legal enactments, by which they can be so far restrained legally, 
as to absolutely prohibit their obtaining intoxicating drinks or indulging 
in their use when their paroxysms, or disposition to do so, shall come on. 
There is just as much propriety in doing this, as there is in restraining a 
person insane in any other way or in any other form. Because these 
periodical drunks are, as has been proven over and over again through the 
generations that are past, dangerous both to the patients and the com- 
munities in which they live, and on the principle of danger to themselves 
and the community, they become proper subjects for legal restraint. The 
same rule in reference to legal restraint applies more forcibly to inebriates 
who become habitually and continuously subject to inebriation, just as 
certainly as the means for gratifying their unnatural desire is within their 
reach. You might as well expect a horse to refuse to put his nose in a 
manger to eat his oats when he is hungry, the oats being there, as to ex- 
pect one of these confirmed habitual inebriates to abstain from taking his 
drink, while left with drink directly before him. He may reason and 
resolve to take no more than a swallow, but the moment this has reached 
the brain the appetite implanted in his perverted nervous organization is 
started and drink will be taken in spite of any number of resolutions and 
pledges. I am speaking now only of those who are confirmed habitual ine- 
briates. Tnere was a time when those of this class, and all the classes of 
periodical drunkards, had power of self-control if they had chosen to ex- 
ercise it; for admitting that there may have been some defect in their 
physical organization that constituted a predisposition or weakness, and 
made them more ready to succumb to the influence of alcohol, more ready 
to acquire what is called a taste for it, still after admitting all this, in the 
early stage of their progress these parties are capable of self-control and 
of abstinence, as proved by the voluntary reform of thousands. Even 
their predisposition does not consist in any taste for alcohol. There is, in- 
deed, no special taste for any particular article of drink whatever. The 
predisposition consists simply of that kind of nervous weakness or feeling 
of exhaustion or readiness to be made weary, that makes them desire 
something to relieve such feelings. The sensations themselves are no 
more suggestive of whisky than of milk or bread; it is only by trial or 
actual experience that such parties learn the anaesthetic effects of alcoholic 
drinks in diminishing their morbid nervous sensations to a greater extent 
than the effects of milk or water. Having' acquired this knowledge by 
trial, they resort to it again and again; and each time they resort to one of 
these agents, its anaesthetic influence helps to produce secondarily the very 
weakness that originally constituted their only defect. The great error 
which helps to keep up the resort to alcoholic beverages, of whatever kind, 
whether fermented or distilled, to remove a conscious weakness, the result 
of a condition of the nervous system in persons of defective natural devel- 
opments or of special hereditary tendencies, is the universal practice of 
speaking of alcoholic beverages as stimulating and supporting agents. 
This is the idea inculcated fro n infancy up by the common language of 
every household as well as by the larger proportion of the members of 
our own profession. And it is this idea in the minds of the great majority 
af individuals, whenever weakness, weariness or physical discomfort exists, 



810 UNCLASSIFIED DISEASES. 

that at once suggests the alcoholic preparations as the agents they need 
to relieve their discomfort. And the deception is readily confirmed in 
them by the temporary anaesthetic effect of the alcohol in diminishing the 
sensibility of the brain, and relieving them of the consciousness of their 
previous morbid impression, while in fact it neither stimulates nor sup- 
ports, but is a direct and positive sedative, debilitating both nervous and 
muscular structures, and diminishing the atomic changes throughout the 
organization. In calling your attention to the class of inebriates who have 
been ranked by some in modern times as laboring under a species of 
derangements called methomania, my object is simply to remind you that 
as physicians it is your duty to study these cases, and to bring the whole 
weight of your influence upon those who depend upon you as guides in 
reference to their health, to correct the errors under which so many in 
every community labor in regard to the real nature and effects of alcoholic 
beverages. I have thus, gentlemen, completed the consideration of the 
diseases which I had grouped under the head of nervous affections, and 
therefore come to the last division of our course, in which I propose to 
consider, briefly as possible, a number of morbid conditions arranged un- 
der the head of miscellaneous topics, which are of frequent occurrence in 
the ordinary routine of practice, often troublesome to manage and con- 
sequently of much importance both to the practitioner and to the patient. 



LECTURE LXXXIV 



Miscellaneous or Unclassified Diseases— Their Variety, and General Remarks on their Causes 
and Tendencies. 

GENTLEMEN: The practitioner of medicine is called upon for advice 
in relation to a considerable variety of ailments, usually of a chronic 
and more or less persistent character, which are not capable of being 
classed properly in either of the divisions or classes of disease that we 
have had under consideration during the present term. Most of the af- 
fections to which I allude have their origin either from hereditary predis- 
position, or from the habitual errors and evil influences that grow out of 
the habits of civilized society, and the various occupations pursued among 
men. That the faulty condition of the physical structure of parents may 
be transmitted more or less distinctly to their children there can be little 
doubt. And throughout all ranks of society in this and other civilized 
countries, there are to be found many individuals who have inherited such 
a degree of imperfection in one or more of the groups of organs which 
make up the animal economy, as to cause the frequent occurrence of im- 
perfections in the performance of functions, and consequently sufferings 
that induce them to seek the aid of a physician. In one class of cases 
this defect may relate particularly to the organs of respiration, in another 
to that of digestion, in others to the development of the different portions 
of the nervous system, while' in still others, the defects will relate more to 
the organs of generation. Such individuals will be regarded everywhere, 
by their medical advisers, as strongly predisposed to this or that manifes- 
tation of disease, sometimes without exciting causes, but more particu- 
larly, on the occurrence of even the slightest provoking cause. But inde- 



CAUSES. 811 

prudently of hereditary influences, there are habits of life and practices 
prevalent in civilized society, which have a tendency to influence chil- 
dren from a very early period throughout their entire development to ma- 
turity or adult age. Those circumstances are sometimes connected with 
the process of education in schools, sometimes connected with their occu- 
pations when they commence some definite occupation early, and in other 
instances, simply growing out of the ordinary modes of dress and diet, 
and the degrees of confinement in-doors, or limit of exercise in the open 
air. It requires but a little practical experience and reflection to see that 
a large percentage of the children of both sexes, and especially of the 
female sex, who are born of parents themselves healthy, and in circum- 
stances favorable pecuniarily and socially, that the predominance of at- 
tention is given throughout the whole period of their education to the 
cultivation of the intellectual faculties and acquisition of knowledge, to 
the great neglect of attention to the equal exercise of the muscular struct- 
ures in different parts of the body, and consequently to the equal develop- 
ment of the physical system. This leads to the development in every 
community of a large number, who, during the whole period of adult life, 
suffer more or less from the predominant development of nervous excita- 
bility, with corresponding enfeeblement of the functions of digestion 
and excretion. Such parties may pass a large portion of life without any 
attack of a definite, well defined form of disease, such as typical forms of 
fever, or of a well marked focal inflammation, and yet have such derange- 
ment of the functions of a minor character as to make them need medical 
advice almost every month in the year. Other classes by the nature of 
their occupation are induced to remain too much in-doors, sometimes oc- 
cupying daily certain positions many hours in succession, and taking no 
habitual regular exercise out of doors from time to time, to counteract the 
evils of that which their labor induces, acquire certain inequalities in 
the performance of the functions of the body. Prominent among these is 
a lessening of the efficiency of the respiratory movements and consequent 
impairment of the changes which take place in the blood while passing 
through the pulmonary organs, constituting deficient oxygenation and de- 
carbenization of the blood. This in turn lessens almost every secretion, 
because blood deficient in the supply of oxygen does not maintain the activ- 
ity of the secretory cells, causing deficiency of secretion from the mucous 
membrane of the alimentary canal, including the gastric juice, with conse- 
quent derangements in the digestion of food and in the regularity of the 
alvine evacuations. The same defective condition of the blood renders it 
incapable of sustaining a healthy tone of the nervous and muscular struct- 
ures, indicated by general lassitude and lack of power of endurance. Such 
patients, without any marked structural changes in any of the organs, 
will have as results from this impairment in the various functions, a 
constant tendency to accumulate enough of the products of tissue disinte- 
gration in the blood to induce once in from one to three weeks a sick 
headache, a paroxysm of indigestion or some other painful illness. 

This kind of headache is termed sick headache or migraine, because 
soon after the commencement of the pain in the head, the morbid in- 
fluence is radiated through the pneumogastric nerve to the stomach in 
such degree as to cause active vomiting. The patient, deprived of 
nourishment, placed at rest, and subjected to thorough and repeated 
vomiting, not only ejects the contents of the stomach, but relaxes the skin 
while under the influence of the nausea and increases the exhalations from 
that source. These changes are generally accompanied by the adminis- 
tration of some medicine that will operate upon the bowels. By such 



812 UNCLASSIFIED DISEASES. 

increased eliminations, in the course of twenty-four or thirty-six hours, 
the retained effete materials that had been accumulating for one, two or 
three weeks, are thrown off. The derangements of the system being thus 
corrected, the headache disappears, and the patient, without pain or sick- 
ness, but feeling less than his usual strength, has a return of his appetite, 
and resumes his work. Being subjected again to the same causes, in 
about the same period of time, the former derangements are re-established, 
and culminate in another attack of headache and vomiting. And thus 
many patients go on with such a train of evils through years, and some- 
times a large part of their lives. In other instances, a similar train of 
causes operating upon persons with less nervous excitability or cerebral 
sensitiveness, they will escape the headaches and vomitings from the 
imperfect performance of the functions of excretion, but will become more 
constipated, the gastric secretion less and less abundant, and consequently 
digestion being performed less perfectly, they come to assume the con- 
dition of confirmed dyspeptics, or to suffer for a time daily from imperfect 
digestion of food. There is usually no burning in the stomach, no general 
fever, pulse quiet, and temperature natural. They seldom emaciate, but on 
the contrary sometimes have a redundancy of fatty deposit in the tissues. 
They hardly take a fair meal, however, from one end of the year to the 
other without having it lay like a weight in the stomach for one or two 
hours after eating. And generally after the first hour has passed, there 
will commence generation of more or less gases, most of the time taste- 
less, but abundant in quantity. They will keep up eructations or belch- 
ing of gases for an hour or more, after which all the symptoms pretty 
rapidly decline, and the patient is feeling comparatively comfortable 
until the next meal, when he goes through the same process. And 
thus from day to day he labors under the influence of gastric discom- 
fort after each meal, rendering his mind despondent and gloomy, his 
nights often broken and uncomfortable by dreams of an unpleasant 
character, until he becomes habitually gloomy, and feels often that life is 
a burden. Most of these patients, in addition to the disturbances of the 
stomach just indicated, have habitually an inactive condition of the 
bowels, requiring frequently the use of laxative medicine to afford them 
relief. The urinary secretion is also high-colored, and when allowed to 
stand sometimes throwing down an excess of phosphates or ammoniacal 
salts, in the form of a white precipitate, which generally causes much 
anxiety on the part of the patient from fear of the supervention of serious 
disease of the kidneys. But this class of patients seldom have anything 
more than functional derangement of the urinary organs. Indeed, the 
continued activity of the kidneys in eliminating an increased quantity of 
the products of disintegration or natural tissue changes, constitutes the 
most reliable conservative process for keeping such patients from more 
dangerous functional derangements. The bowels being constipated, the 
skin dry, the kidneys are more persistent in executing their function than 
any other eliminating organs or structures in the system. Another class 
of patients whom you will meet with, on whom have been operative some 
of the same causes that I have already pointed out, when their derange- 
ments have arrived at that degree of development characterized by 
deficient gastric secretion and consequent indigestion, instead of going 
on to the development of disturbance of the brain and paroxysms of sick 
headache, or of habitual constipation and complete indigestion, stop at a 
point where the disorder of digestion is only moderate. This moderate 
gastric disturbance, however, is sufficient to establish a certain grade of 
morbid sensitiveness in the branches of the pneumogastric nerve through 



SYMPTOMS. 813 

which the morbid sensations induced by the contact of food in the 
stomach are reflected directly back along that nerve, sometimes only to 
the point where the cardiac branches leave the pneumogastric trunk, and 
produce disturbance in the heart's action. And consequently within a 
given time after each meal, the patient no sooner begins to feel slight 
indications of uneasiness in the epigastrium, or stomach proper, than his 
lace becomes flushed, a sense of heat comes over him, and the heart 
begins to beat with a much greater degree of frequency and force than 
natural. After one or two hours he will be in great anxiety of mind from 
the excited or irregular action of the heart. For the cardiac disturbance 
may consist of simply increased frequency and force of beat, or it may be 
more or less irregular, beating rapidly and forcibly three or four beats 
and skipping one, or intermitting, or without the actual intermission, 
varying so rapidly from rapidity and force to that of slowness, as to 
create almost constantly the impression in the mind of the patient that 
there is serious disease of the heart, and he consequently becomes very 
despondent. Not infrequently the chief cardiac disturbance comes 
during the night, especially in parties who are in the habit of drinking too 
much strong tea. They no sooner get quiet in bed, or at most begin to 
catch short periods of sleep, than the heart will begin its unpleasant ex- 
citement and irregularity of movements, and they will feel obliged to sit 
upright in bed sometimes half the night, with the hands over the cardiac 
region, and the mind filled with anxiety from the impression that they are 
in danger from serious disease of that organ. As morning comes on, the 
stomach becomes emptied of its contents, the reflex irritability subsides, 
and the patient is quiet and comfortable. The most careful examination 
in the morning would detect no error in the circulation whatever, or in 
the movements and sounds of the heart. Closely allied to these cases are 
those in which the reflex disturbance extends trom the stomach to the re- 
current branches of the pneumogastric nerve, causing contraction or a 
sense of choking in the neck. This symptom is frequently associated 
with the irregular and excited cardiac movements just described, causing 
the patient, for the time being, the most distressing feelings of impending 
death from suffocation or complete suspension of the action of the heart. 
I allude to these modes by which distressing symptoms of various kinds 
are developed, of a character difficult to classify, and yet of so frequent 
occurrence as to constitute an important part of every physician's practice 
who may reside in a populous community, as represented by cities or 
large villages. Yet, as in other ailments, the patient will be, in many 
instances, anxious for the doctor to give him the name of his disease. He 
wants this not only for his own satisfaction, but that he may tell all his 
neighbors also. This anxiety to have a name given to their disease has 
induced many members of the profession to use certain vague terms that 
satisfy the popular mind without conveying any definite knowledge. In 
former times, nearly all of these ailments were classified under the head of 
biliousness. Simply, because when the doctor was pressed to know what 
the matter was, he found it more convenient to give them a name that 
they would think they knew something about, than to try to explain the 
complex derangements of function which really constituted their 
difficulties, and which if he explained ever so minutely not one in a 
hundred of the patients would be capable of understanding his explana- 
tion. Hence, the common practice of telling such persons that they are 
bilious had led to the almost universal adoption of this term for covering 
most of the nameless or unclassified ailments in the community. In 
recent times, however, biliousness has found a popular competitor in the 



814 UNCLASSIFIED DISEASES. 

expressions nervous prostration, nervous exhaustion or neurasthenia. 
These latter names are especially applied to such cases as involve head- 
aches, sleeplessness, palpitations, and all the other troubles in which the 
nervous phenomena are most prominent. I would no.t do justice in these 
general observations, however, if I failed to mention another class of cases 
consisting almost entirely of members of the female sex, who, through 
errors consisting chiefly in the modes of dress, such as leaving the feet 
and ankles imperfectly protected during the cold seasons of the year- 
while a large proportion of the weight of all their clothing is hung upon 
the body by close attachments directly around the waist, and that part of 
the trunk on a horizontal line with the epigastrium. By such methods 
the epigastric and hypochondriac regions are compressed, thereby 
crowding the abdominal viscera downward, and on the one hand favoring 
depression of the pelvic organs and on the other limiting materially the 
freedom of the expansion of the lower part of the chest. This lessens by 
a few cubic inches the volume of air habitually taken at each inspiration, 
and correspondingly lessens the efficiency of the oxygenation and decar- 
bonization of the blood. A large class of females coming to maturity 
under such modes of dress suffer almost continuously from some degree 
of impairment of the digestive functions, habitual torpor or inactivity of 
the bowels, a ready nervous excitability, giving rise frequently to head- 
aches, sometimes to palpitations, especially if they indulge early in the 
use of tea and coffee; imperfect rest at night, but more prominently than 
all, pains in the back and loins whenever much upon their feet, either 
in standing or walking. Many of this class also suffer pains in the 
inguinal regions or in the direction of the uterine ligaments whenever 
any considerable exercise is taken, and during the early part of adult life 
are almost certain to have severe suffering during every period of 
menstruation, more particularly a day or two preceding the commence- 
ment of the flow, or during the first day of the flow itself. In some 
instances these pains are moderate, in others excruciatingly severe; so 
much so, that each period leaves them more or less debilitated and de- 
pressed, requiring half of the interval before the next period to recover 
from its effects. Many who do not thus suffer pains at this time, either 
have the flow too often, as every three weeks instead of four; and if not 
too often, so freely as to occasion an excessive loss of blood. Whether 
the flow is excessive or not, a leucorrhceal discharge is apt to follow for 
a week or ten days after the true menstrual flow has ceased. In nearly 
all such cases, the leucorrhceal discharge is thin, white and of a serous 
character. Occasionally it will be more purulent, and sometimes more 
decidedly of a mucous character. This latter class always or almost 
always present a pale, anaemic aspect and are very easily tired. They 
complain of weariness on the slightest exertion and are incapable of en- 
during more than a very moderate amount of fatigue. 

If you would discharge your whole duty as a medical adviser of such 
patients, in the attempt to remove their difficulties, and render their lives 
more happy and of longer duration, instead of limiting your efforts to the 
mere function of temporarily warding off whatever evils may be present 
at the time, you will in addition faithfully and honestly endeavor to re- 
move the causes which have led to their suffering. There is no depart- 
ment in the whole field of practice which affords the physician who would 
acquire a reputation in the beginning of his professional career, that is so 
important if well cultivated, as that occupied by the great class of chronic 
invalids. For it is the large class of patients who are suffering from these 
unclassified ailments, consisting in impairments of one or more important 



SPASMODIC ASTHMA. 815 

functions, rendering them supplicants who go from one physician to an- 
other, and then from the physician to the mountebank or medical pre- 
tender, and from him to the newspapers, and the drug manufacturers for 
their advertised nostrums, for the simple reason that the physicians they 
had consulted failed to take that interest in the cases which is necessary 
to trace out their origin, and to faithfully, honestly, and yet kindly, inform 
them of the sources of their evils and impress upon them the necessity 
of correcting and obviating the causes, as an absolute prerequisite to any 
permanent improvement. Having made these general observations suffi- 
ciently simple to indicate to you, in general terms, the sources to which 
you are to look in tracing out the causes which may have been operative 
in producing the affections you may be called upon to treat, belonging to 
the class now under consideration, I will proceed to the consideration of 
the more important of these derangements in detail; taking first, those in 
which the more prominent sj^mptoms are connected with the respiratory 
organs; next with the circulatory; third the digestive, and lastly the or- 
gans of excretion. The principal derangements of which I shall speak, 
connected more prominently with the respiratory organs, are spasmodic 
asthma, laryngismus stridulus or spasmodic croup, aphonia and exoph- 
thalmic goitre. Those in which the prominent symptoms are manifest 
through the circulatory system will be grouped under the heads of angina 
pectoris, cardiac irritability and palpitations, fatty degenerations in the 
heart and vessels, aneurisms, and emboli. Those affecting the digestive 
organs I shall group under the heads of indigestion or dyspepsia, gas- 
tralgia, constipation and intestinal parasites. Those affecting the excre- 
tory organs more particularly, will include diabetes mellitus and insipidus, 
eneuresis, lithiasis, urinary and biliary calculi, and defective eliminations 
from the skin. In connection with the excretory organs, I shall also 
allude to those rare developments of cysts, embracing echinococci in the 
liver and kidneys ; also a brief consideration of the special toxasmic con- 
ditions of the blood usually included under the terms septicaemia and 
pygeinia. 



LECTURE LXXXV. 

Spasmodic Asthma and Laryngismus Stridulus— Their Causes, Symptoms, Diagnosis, Prognosis 
and Treatment. 

GENTLEMEN: In the ordinary field of general practice cases are not 
infrequently met with of a purely spasmodic or functional character, 
affecting the respiratory passages, more particularly the larynx and the 
smaller bronchial tubes. They do not constitute distinct diseases in the 
proper sense of the word, but rather symptoms of some preceding patho- 
logical condition, on which the existence of the paroxysms of contraction 
in the larynx and bronchial tubes depend. They are manifest almost in- 
variably in paroxysms of temporary duration. When affecting the bron- 
chial tubes and giving rise to much dyspnoea, or asthmatic breathing, they 
are more frequently m3t with in adult life. A similar condition affecting 
the larynx is much more frequent in children, although it may occur dur- 
ing any period of life. During the paroxysms the chief symptoms, when 
affecting the bronchial tubes and taking the ordinary name of asthma or 



816 SPASMODIC ASTHMA. 

spasmodic asthma, consist of very decided constriction or difficulty of 
breathing, causing a sense of suffocation, and great oppression or tightness 
in the chest, accompanied by more or less wheezing or dry hissing, sibilant 
and sonorous rales, which are heard throughout the whole chest, both ante- 
riorly and posteriorly. At the same time that the patient experiences 
these difficulties, the oppression and laboring for breath, accompanied* by 
wheezing, dry rales, the face becomes more or less suffused with redness, 
sometimes more of a leaden or purplish hue; the patient assumes the up- 
right position, leaning a little forward, endeavoring to rest the elbows 
upon the knees, so as to form a point of support to aid the extraordinary 
motions of the chest. The expiratory acts are almost as difficult as the in- 
spiratory, and nearly of the same length. If the paroxysm continues more 
than a few minutes the patient feels an extreme sense of weariness, the 
skin becomes relaxed and bathed with perspiration; the pulse soft, weak, 
and a little accelerated in frequency; a sense of oppression, almost of 
drowsiness, comes over the patient, and yet he has entire inability to sleep, 
causing an extreme sense of weariness and exhaustion. These paroxysms 
continue a variable period of time, from not more than fifteen or twenty 
minutes to six or eight hours. They much more frequently manifest 
themselves during the night, usually after the patient has fallen asleep. 
He is started up from his sleep by a sense of suffocation and oppression, 
and usually throws the windows and doors open for fresh air, and gener- 
ally insists on keeping the upright position or inclining forward as I have 
already mentioned. Commencing in this way, usually in the early part 
of the night, after the first half hour or hour of sleep, it will usually con- 
tinue till near morning; in most cases, from three to four o'clock in the 
morning, the difficulty of breathing will gradually diminish, air will enter 
more freely to the air cells, and the patient will soon obtain a sense of re- 
lief from the suffocation, and in half an hour more reclines at an angle 
of forty-five degrees, having the : head still moderately high, and falls 
asleep. The patient usually perspires freely, and often sleeps four or five 
hours, if left undisturbed, and wakes up feeling weary, but with entire 
freedom of breathing; the rales are gone from the chest, the pulse is 
natural in frequency, and nearly so in force, and no symptom or physical 
sign remains to explain the apparent obstruction and great dyspnoea that 
had characterized the paroxysm. These latter may recur every night, or 
they may occur only at entirely irregular intervals, depending upon certain 
other derangements which precede them. They do not, like bronchitis, 
or the dyspnoea from inflammatory affections of the respiratory organs, 
occur more frequently in cold seasons of the year. But this spasmodic 
variety of disease may recur at any and all seasons of the year. It is re- 
garded as of more frequent occurrence in males than in females. As I 
have already remarked, it is a symptomatic affection, and may be caused 
by derangements either connected with the digestive organs, which is 
perhaps more common than any other, or from some peculiar suscepti- 
bility, or genuine idiosyncrasy of the nerves connected with the air pas- 
sages. The most common cases of all, are those which are directly de- 
pendent on primary derangements of the function of the stomach. Di- 
gestion being imperfect, the patient retiring to bed with more or less un- 
digested food, and deficient gastric secretion, the stomach soon becomes 
more or less distended with gases, and their action with other morbid 
products in the stomach produces an impre. sion upon the gastric branches 
of the pneumogastric nerve, which is reflected through the connections of 
that nerve upon those supplying the delicate muscular fibers entering 
into the coats of the bronchioles and smaller bronchial tubes, inducing a 



CAUSES. 817 

genuine spasmodic contraction of these fibers, and a narrowing of the 
tubes, which is the immediate cause of the paroxysms of dyspnoea. Af- 
ter the derangement of the stomach is relieved by the discharge of the 
gases and other materials so as to remove the exciting cause, the asthmatic 
paroxysms speedily subside. But if no measures are taken for prevent- 
ing a renewal of the gastric disorder, the dyspnoea will also recur in par- 
oxysms more or less frequent. Almost any marked derangement in the 
digestive organs is capable of inducing reflex irritation that will bring 
temporary paroxysms of dyspnoea or asthmatic breathing. There are 
some persons, however, who possess a peculiar idiosyncrasy in the sensi- 
bility of the nerves connected with the respiratory organs, by which they 
are made liable to an attack of spasmodic asthma whenever certain sub- 
stances diffused in the atmosphere are allowed to enter the air passages 
by inhalation. Certain powders, with these persons, will immediately de- 
velop a temporary paroxysm of this disease. Powdered ipecac and the 
odor or pollen of certain flowers and plants, have been known invariably 
to induce paroxysms of the disease in persons thus predisposed. It is un- 
doubtedly true, that aside from actual idiosyncrasy in this respect, there 
are some cases in which ordinary causes have produced that degree of 
morbid sensitiveness in the bronchial nerves that renders the patient 
liable to be thrown into paroxysms of spasmodic dyspnoea on the slightest 
provocation. A slight morbid sensibility in any portion of the anterior 
lobes of the brain extending back far enough to involve the origin of the 
pneumogastric nerves may render the individual very sensitive to moder- 
ate impressions, or what is popularly styled exceedingly nervous or easily 
excited. A few instances of that class I have known to be subject to 
paroxysms of great difficulty of breathing, almost uniformly from any 
sudden emotion, or strong mental impression. Almost any variety of sud- 
den and decided mental excitement would be sufficient to bring on par- 
oxysms of difficulty of breathing, resembling in all respects spasmodic 
asthma, and usually lasting from five minutes to an hour. I have partic- 
ularly in my mind at the present time a woman, aged about twenty-three 
years, who for the last three years has been affected with this form of dif- 
ficulty, coupled with a simultaneous spasmodic affection of the larynx. 
And so sensitive has she become that great care is required to avoid the 
moderate mental disturbances which may occur in almost any intercourse 
in society, lest a paroxysm should be induced. And they become so fre- 
quent as to render the patient's life exceedingly troublesome, and the 
mind habitually despondent. Yet the closest scrutiny could not detect 
any organic or structural changes, nor inflammatory affections either in 
the larynx, or any part of the bronchial ramifications. When a similar 
paroxysmal constriction takes place in the larynx as I have described as 
occurring in the bronchial tubes, which often happens in children, it con- 
stitutes laryngismus stridulus or spasmodic croup. And it may arise 
from any and all the causes I have alluded to, as producing the asthmatic 
difficulties. There being a predisposition consisting of undue sensitive- 
ness of the nerves of the larynx, any slight irritating influence, whether 
the inhalation of impure air, irritating vapors, or being exposed to chilly 
night air will be sufficient to provoke an attack. Perhaps the most fre- 
quent causes are the sudden impression of cold and damp air, or even 
allowing the feet to get unusually cold, and temporary derangements of 
the digestive organs, especially the formation of gases in the stomach at 
night. An attack is most liable to supervene after the first hour or two 
of sleep, when the patient awakes suddenly with a sense of suffocation, 
and such a contraction of the muscular structures connected with the 
i2 



818 LARYNGISMUS STRIDULUS. 

larynx and vocal cords, as to produce great difficulty of inspiration and 
inclination to cough, with loud, ringing, stridulous sounds, as though the 
patient had suddenly developed the most dangerous form of croup or 
laryngitis. The parox}^sm thus developed will usually last from one to 
three or four hours, when it subsides, leaving the patient almost entirely 
free from any conscious difficulty, either in the breathing, or in the tend- 
ency to cough. This, like the asthma, may be renewed each night for 
several nights in succession, or it may come only in individual paroxysms 
at irregular and sometimes long intervals. Both this affection, so com- 
mon among children, and the spasmodic asthma, are distinguished from 
the difficulty of breathing which we have already described in connection 
with inflammation of the larynx and bronchial tubes, by the fact that the 
active symptoms are all purely paroxysm il, in the interval there remain- 
ing no physical signs even of congestion of the mucous membrane in 
those passages. This of course is not the case in either laryngitis or 
bronchitis; while there will be paroxysms of difficulty of breathing in the 
latter instances, in the intermission between the paroxysms the patient 
still has some degree of difficulty and the physical signs of congestion 
still remain as constant phenomena till the disease is removed. Another 
marked distinction, is, that in the inflammatory affections of the larnyx 
and bronchial tubes the temperature of the patient is increased, consti- 
tuting more or less febrile movement, the pulse is accelerated, while in 
the spasmodic affection there is no increase of temperature, more fre- 
quently rather a diminution, and the pulse has none of the short, quick, 
febrile quality, that belongs to the inflammatory affections I have named. 
As these spasmodic affections seldom if ever prove fatal, there are no an- 
atomical changes known to be characteristic of their existence. 

Treatment. — As you will have inferred already, from the fact that the 
spasmodic affections I have described are symptomatic, always arising 
from some prior pathological condition found in other organs, the respira- 
tory trouble being only from reflex influence, the great and leading ob- 
jects of treatment are: first, to hasten the relief of the patient from the 
existing paroxysm, when called during its existence, while the second, 
and more important object is to ascertain the pathological conditions from 
w T hich the troublesome paroxysms originate, and adopt such measures as 
may be indicated for their removal. For accomplishing the first object, it 
is sufficient to bring the patient quickly under the influence of almost any 
reliable antispasmodic and slightly anodyne remedy. The cautious in- 
halation of at) anesthetic, like chloroform or ether, still better the nitrite 
of amyl or the vapor of the oil of eucalyptus, will in many cases speedily 
relieve, the existing paroxysm. So will the internal administration of a 
combination of almost any mild anodyne with an expectorant. A com- 
bination of the camphorated tincture of opium with the compound syrup 
of squills, to which may be added a certain proportion of the tincture of 
lobelia inflata, constitutes, perhaps, one of the most efficient that can be 
made for the relief, both of the laryngeal spasm and the asthmatic parox- 
ysms. A prescription, consisting of the compound syrup of squills thirty 
c. c. (|i), tincture of lobelia fifteen c. c. (§ss) camphorated tincture of 
opium forty-five c. c. (fiss), may be made, of which four cubic centime- 
ters, or one fluid drachm, diluted with a tablespoonful of water may be 
given to an adult at once. It may be repeated in one or two hours, if re- 
lief is not sooner obtained. The same combination, only reducing the 
dose so as to adjust it to the age of the patient, may be given to children, 
particularly for the relief of what is commonly known as spasmodic croup. 
Where the lobelia might be objectionable on account of its tendency to 



TREATMENT. 819 

excite too much nausea or sedative action, an equal quantity of the tinct- 
ure of sanguinaria m-iy be substituted in its place. In some instances I 
have seen very speedy relief result from giving proper doses of an equal 
mixture of the fluid extract of grindelia robusta, and camphorated tincture 
of opium. Many families having children who are somewhat predisposed 
and consequently are frequently attacked with this variety of croup or spas- 
modic laryngeal affection, keep constantly on hand the ordinary syrup of 
ipecac, and whenever the children are attacked, sufficient is given to pro- 
duce nausea or slight vomiting, which causes relaxation of the parts 
involved, and the paroxysm passes off. But the more important part of 
the treatment in all such cases is to ascertain as accurately as possible the 
derangements which precede and give rise to the phenomena that we 
have been discussing, that such measures may be adopted as will remove 
them and thereby prevent the recurrence of future paroxysms. Those 
cases which depend upon some natural idiosyncrasy rendering the patient 
liable to attacks either of laryngeal or bronchial spasm, from inhalation 
of certain substances in the atmosphere, are probably incurable. They 
are, like other idiosyncrasies, congenital and usually continue through the 
whole period of life. Yet in some instances they have been known to 
gradually diminish after the middle period of life, and finally disappear. 
When there is morbid sensitiveness of the nerves of the air passages, 
accompanied by a general nervous temperament, constituting a condition 
that is easily impressible from almost any cause, the object of the 
physician should be to give such instructions to the patient or his parents 
and guardians as will enable them to adopt a system of training calcu- 
lated intelligently to change this morbidly sensitive constitutional con- 
dition to one more healthy, and thereby do away with the unpleasant 
consequences that would otherwise annoy the patient through life. 
Among the measures most important for such patients is the wearing of 
flannel next to the surface during all the cold, damp and variable seasons, 
which in the northern part of this country would embrace nearly all the 
year, living upon plain, easily digestible food, and a regular daily practice 
of moderate out-door exercise, including positive exercise of the chest and 
arms, thereby cultivating strength and efficiency in the muscles concerned 
in carrying on the involuntary process of respiration. In some cases 
during the last two or three years, I have obtained considerable advantage 
by causing the patient to inhale, for three to five minutes at a time, the 
vapor of the oil of eucalyptus morning and evening. This vapor appears 
to exert a sedative effect upon morbid nervous sensibility, and to excite 
healthy secretory action in the mucous follicles of the membrane lining 
the air passages. In that large class of cases of spasmodic bronchial 
affection existing in connection with, and sometimes dependent upon, 
derangements of digestion, the only rules that can be laid down for their 
management is to adopt such measures in regard to diet, exercise and 
medicine as are required for the effectual correction of the digestive 
derangements, including regulation of the bowels and the promotion of 
the natural secretions, especially from the skin and kidneys. For obser- 
vations show that a large proportion of the cases where, from gastric 
derangements, the air tubes are frequently constricted, interfering more or 
less with the uniformity of the functions of the lungs, the urine is very 
liable to become impregnated with a large excess of the phosphatic and 
ammoniacal salts. In such cases, the urine on cooling deposits a large 
amount of a white or pinkish white color, which is wholly dissipated by 
heat or nitric acid. All these derangements affecting digestion and the 
important eliminations from the kidneys and skin, require the attention of 



820 APHONIA. 

the practitioner if he would succeed in permanently restoring the patients 
to reliable health. Among other things it often becomes necessary to 
correct the patient's mode of doing business, or the kind of work in which 
he is engaged. For many of this class will be found either so occupied 
as to be kept an inordinate amount of time in-doors, very frequently in 
confined air, or sleeping in close, poorly ventilated and warm rooms at 
night. Sometimes they are engaged in occupations where the air is 
impregnated continuously with some foreign substance, as in the manu- 
facture of tobacco, and various other manufacturing processes that cause 
habitual impregnation of the air which the workmen are obliged to inhale. 
Another difficulty occasionally met with in direct connection with the 
respiratory passages, more particularly with the larynx, is that of aphonia 
or loss of voice. 

Aphonia. — When speaking of laryngitis in all its various grades, you 
will remember that we had alterations of the voice in every degree, from 
that of the loud, harsh and ringing, to entire suppression or reduction of 
the voice to a whisper, accompanying most of the inflammatory conditions 
of that part of the respiratory apparatus. But, aside from this, there are 
conditions of the nervous system which are accompanied by entire 
aphonia or loss of voice. This is not of very frequent occurrence, and is 
chiefly met with in females of a highly nervous or hysterical tempera- 
ment. In this class of patients, many cases have been observed in which 
from sudden mental impressions or the paroxysms of high nervous excite- 
ment, the voice has been suddenly lost, the patient being entirely unable 
to articulate a sound or to make any audible sound above that of a 
whisper. Such cases are distinguished from inflammatory affections by 
the entire absence of soreness, pain or any of the phenomena of inflam- 
matory action, and when examined for the physical signs by the laryngo- 
scope, or even by listening over the larynx with the ordinary stethoscope, 
there is absence of all the signs that accompany inflammatory congestion 
or exudation in the membrane lining the larynx, or covering the vocal 
cords. In most such instances, a careful inspection of the parts with the 
laryngoscope shows either partial or complete paralysis of the functions 
of the vocal cords. In some instances, the loss of voice is felt for a few 
minutes, and in others it lasts for days or weeks. Perhaps the most 
efficient agent, which is calculated to act quickly in restoration of the loss 
of voice from paralysis or from suspension of the natural action of the parts, 
is that of electricity applied by faradisation, or any other method by which 
electric or electro-magnetic currents of a moderate degree of intensity 
are made to pass through the parts involved. The application may be 
continued from five to ten minutes at a time, and sometimes results in at 
once re-establishing natural action. At other times it requires an appli- 
cation each day for several days. If the patients are troubled at the same 
time with other nervous phenomena, the use of such nervous sedatives, 
antispasmodics and tonics as may be indicated to improve the generai 
condition of the patient will also assist in restoring the action of the vocal 
cords. If such patients are debilitated, requiring the influence of tonics, 
perhaps one of the best that can be given for preventing a recurrence of 
the aphonia after the voice has been once restored, or even during the 
process of the restoration, is the combination of moderate doses of strych- 
nia, quinine and iron. They are agents that may be very conveniently com- 
bined in proper proportion in doses to suit the age of the patient, in gela- 
tine capsules, and administered without annoyance to the patient. Although 
not usually mentioned by writers upon practical medicine, there is a class 
of patients which you are liable to come in contact with who are, as you 



SYMPTOMS. 821 

will find, very much alarmed at tim^s with a smse of difficulty of breath- 
ing, or rather a sense of want of breath ami weakness across the cl 
Usually, in the paroxysms they present a pale and anxious expression of 
countenance, almost always sitting upright in the bed or chair, and when 
you approach them complaining with irreat alarm that they are suffocating 
or cannot breathe; and yet, aside from the expression of countenance I 
have mentioned, you find on further examination that the pulse and tem- 
perature are natural and no rales in the chest. But in watehinor them for 
a moment or two you will observe that the inspiratory and expiratory 
movements are performed imperfectly or inefficiently, perhaps for five or 
six respirations, and ending in a deep, sighing inspiration by which the 
patient apparently seeks instinctively to compensate himself for the 
defectiveness of the respirations that occurred between these sighings. 
The mechanism of the breathing in these cases is not that of asthma or of 
any constriction of the air passages. It is rather impairment of the 
function of the nerves connected with respiration, and a condition of the 
bronchial tubes similar to that which involves the vocal cords and larynx 
in aphonia. It is a direct, though temporarv, impairment of the function 
of respiration, the respiratory movements being so defective that the 
patient feels a sense of impending suffocation, or as though the 
mechanisms of respiration and circulation were about to stop. I have 
met with such cases more frequently in females who are in the habit of 
using freely and habitually strong tea than in any other class of subjects; 
but it has not been restricted altogether to them. I have met with the 
same phenomena in adults of the male sex, and in some instances of 
females who are not addicted to the use of any inordinate amount of tea 
or coffee. But perhaps a large proportion of all I have seen have been 
subject to the excessive use of those agents, and more especially of the 
tea. Amonof the more common cases of the kind are women who are 
nursing. "Within the first two or three months after their confinement, 
following the popular notion that while nursing thev must take an extra 
amount of drink, and that tea helps to form milk, they acquire the habit 
of taking sometimes from six to twelve ordinary cups of strong tea in the 
twenty-four hours. Occasionally one takes less, but substitutes in place 
of it beer, ale or porter. These patients almost invariably lose their 
appetite for food and consequently eat but little, depending altogether 
upon their drink; the result of which is that the theine of the tea being a 
direct nervous excitant, increases the inherent susceptibility of the nerve 
structures and in process of time develops an extraordinary impressibility 
or excitability of the nerves that are more particularly connected with the 
heart and respiratory organs. The use of the beer and ale modifies the 
effect but little, while it aids in destroying the appetite for wholesome 
food, and the patient becomes more or less impoverished in the nutritive 
elements of the blood and subject almost every night and sometimes 
during the day to those distressing feelings of oppression and inability 
to breathe, occasionally accompanied by irregular action of the heart. 
I have many times been called in the night to patients of this class, under 
the positive assurance that they were in danger of dying, and when I 
arrived, found them sitting in bed, as I have described, pale, anxious, skin 
bathed in perspiration, but cool, and not a shadow of physical evidence of 
obstruction in any part of the air passages, and the heart perfectly free 
from evidence of any structural or valvular change; the whole difficult v 
being dependent upon the impairment of nerve function in carrying on 
the mechanical process of breathing. For immediate relief to such 
patients, I have found no remedy more efficient than a combination of 



822 CARDIAC IRRITABILITY. 

digitalis, Scutellaria and valerian in such proportions that with each dose 
of four cubic centimeters (fl. 31) the patient would get two cubic centi- 
meters (fl. 3ss) of the fluid extract of valerian, one cubic centimeter 
(min. xv) of the tincture of digitalis, and the same quantity of the fluid 
extract of Scutellaria. This dose may be given disguised in a little 
sweetened water, and repeated every two hours until the patient is 
relieved from immediate distress. And the same given morning, noon 
and night for a week or two after the immediate paroxysm has passed 
away will contribute much to prevent its recurrence. But the great 
reliance for the cure of such derangements is in the removal of the causes 
that have led to them, viz., the discontinuance of all excess in the use of 
tea and coffee, restricting the use of these agents to one cup of moderate 
strength at a meal-time, requiring patients, if they really need more 
drink, to take milk or water, and the entire disuse of all fermented or 
distilled drinks. At the same time require them to moderately exercise 
in the open air every day, either by riding or short walks, as their strength 
will allow, and to take plain, easily digestible food at the regular meal- 
times. Obedience to these requirements will serve to restore almost 
every one of them in a few weeks to a fair appetite, ability to sleep well, 
or in other words, a reasonable degree of health. Yet, I have seen many 
of these cases that had not been well understood, and in consequence had 
suffered for a longer period of time, and some cases of nursing women who 
actually took the child from the breast at an unreasonably early period, 
under the impression that there was no chance of recovery without doing 
so. Next to the nursing women, the parties most frequently affected 
with this kind of functional difficulty are servant girls who are employed 
in-doors, and especially in the kitchen. Taking but little outside air and 
contracting the habit of using an inordinate amount of tea, large numbers 
of them suffer more or less from the kind of derangement that I have 
indicated, coupled with a tendency almost constantly, to constipation of 
the bowels, impairment of appetite^ impairment of digestion, till some of 
them become disabled from the prosecution of their work. And yet it 
only requires diligence in ascertaining their habits to arrive at a proper 
appreciation of the causes and remove them, when health may soon be 
restored. 



LECTUKE LXXXVI. 

Functional Derangements of the Central Organs of Circulation— Cardiac Irritability. 

GENTLEMEN: Closely allied to the class of cases to which I was 
directing your attention at the close of the preceding lecture is an- 
other, embracing a less number of patients, bat still not very rare. I 
allude to what I shall denominate simple cardiac irritability from nervous 
derangement or perversion of nervous function. The cases to which I 
now allude will be best understood by a brief enumeration of the more 
prominent symptoms. They are met with much more frequently from 
the period of puberty to twenty-five or thirty years of age. It is only 
seldom that I have met with cases beyond the latter period of life. In 
most instances the patients have been spare in flesh, slightly anaemic in 
their appearance, presenting wnat would be denominated a nervous 



SYMPTOMS. 823 

temperament, aud very generally sedentary in their habits, or following 
some occupation that keeps them most of the time in-doors. The prom- 
inent symptom which causes this class of patients to seek the advice of. 
the physician, is rapid beating of the heart. When fully characterized, it 
is not ordinary palpitation of the heart, such as comes frequently a few 
moments at a time and subsides, but it is a continuous rapid beating. 
In some of these cases I have found it difficult to count the beats of 
the heart from its rapidity. The systolic action was short, quick and re- 
peated so rapidly, that no distinction between the first and second 
sounds could be recognized. Of course the pulse has the same degree of 
rapidity, and is almost always soft, easily compressed or weak. The 
respirations are habitually accelerated, but not in comparison to the 
degree of acceleration of the pulse. There is often a continual feeling of 
oppression, especially behind the lower part of the sternum, which 
prompts the patient every now and then to take a deep inspiration or 
sigh. There is no febrile movement, no physical sign of pericarditis or 
endocarditis. Some of these cases where the cardiac irritability or 
extreme rapidity of action has continued from one to three weeks, render- 
ing it difficult for the patient to sleep at night, it has resulted in much 
general debility, as well as a constant feeling of anxiety and oppression. 
A majority of this class of cases, however, do not have the periods of 
cardiac excitement continue so long, but they will recur in paroxysms. 
From slight undue mental excitement and slight exertion it will return. 
upon them with full development of its rapidity and continue perhaps one 
or two hours, then gradually subside, leaving them again comparatively 
free till some slight cause produces its return. They may be subject to 
these paroxysms two or three times in the twenty-four hours, but in some; 
instances it comes the same time once every day, for several days and 
nights in succession. Close examination of such of these patients as have 
come under my own care has revealed the fact that they have either 
suffered themselves to be kept too continuously in-doors, with almost con- 
stant mental application, or that they have been subject to some special 
disturbing influence of a depressing character operating upon thenervous; 
system through the mental emotions and affections. Sometimes grief 
from loss of friends has produced it. In some- instances it has resulted 
from severe disappointment or the sudden breaking off oi attachments, 
and in a very few instances I have found it in connection with cases of f 
long-continued and excessive self-abuse. All these cases of course are 
to be distinguished or differentiated, both from structural disease of the 
heart and inflammatory affections of that organ by careful attention to 
the physical signs. In some instances, where the heart at the time of 
the physician's visit is beating with the rapidity I have described, he may 
be uncertain as to whether there is organic change in the valvular struct- 
ure of the heart, from the mere fact that he can not analyze the rhythm. 
In all such instances he may properly leave a completion of his diagnosis 
until he has subjected the patient to some suitable remedy for steadying 
the heart's action, till the paroxysm has passed awajr, and he has oppor- 
tunity to examine the patient again when the cardiac systoles are nearer 
their natural frequency. This will enable him, without any doubt what- 
ever, to perceive that there are no murmurs or other signs indicating 
structural change. 

Treatment. — The treatment of this class of cases, like the other symp- 
tomatic disturbances to which I have been calling your attention, embraces 
two objects; the one to relieve more directly the excessive cardiac action, 
and the other to remove the cause. In almost all cases that have come 



824 ANGINA PECTORIS. 

under my care I have succeeded in accomplishing the first object by the 
use of the same combination of the fluid extracts of valerian, Scutellaria 
and digitalis that I gave you in the preceding lecture. By giving it in 
moderate but frequently repeated doses, the digitalis soon controls the 
cardiac excitement, while the other ingredients lessen the general nervous- 
ness and sustain the strength of the patient. Whenever this effect is in- 
duced, to prevent exaggerated action of the digitalis the intervals between 
the doses must be greatly lengthened, aiming only to perpetuate sufficient 
influence to steady and strengthen the heart's movements without unduly 
diminishing their frequency, and without producing constriction of the 
chest. There are many other remedies which will afford relief tem- 
porarily. Fluid extracts of cactus grandiflora and convallaria, either 
alone or in combination with other mild tonics and antispasmodics will 
generally produce the desired effect. When, through the direct inter- 
ierence of medicine, the patient is relieved in a great measure from the 
immediate embarrassment of the circulation, the next important object 
should be the removal of the causes which may have led to it. And as 
this almost invariably involves either the occupation or the habits of the 
patient, it is necessary that these be pointed out and that the patient be 
fully and explicitly warned of the necessity of changing them if he would 
make any permanent recovery. Mental application must be limited 
within a reasonable length of time each day, and thereby allow a reason- 
able time for out-door exercise, and especially exercise of the chest by full- 
ness of respiration and free movements of the arms. All those habits which 
would impair the general tone of the nervous system must be omitted. 
The sleeping room must be well aired or ventilated, and of sufficient 
capacity to supply the patient with fresh air during the whole of the 
night. Complete avoidance of such nervous excitants as tea and coffee, 
such anaesthetics as alcoholic liquors and tobacco, must be practiced. 
The patient should be left on pure air, moderate out-door exercise, a 
reasonable limit to mental applications, and there will usually be no 
difficulty in bringing about a permanent change, with sufficient physical 
vigor and health to secure relief from all danger of future attacks. 

ANGINA PECTORIS. 

The next subject to which I will direct your attention is usually de- 
nominated angina pectoris and sometimes neuralgia of the heart. It 
generally occurs in persons past the middle period of life, and perhaps 
more frequently in men than in women. It is also noticed very frequently 
among those who are leading sedentary lives, following occupations that 
keep them much in -doors, and a large proportion of them are addicted to 
the habitual use of strong tea and coffee. The symptoms of this affection 
usually supervene suddenly, though sometimes a dull, aching, depressing 
pain is felt in the cardiac region, gradually increasing through several 
hours before the paroxysms become fully developed. In most instances the 
patient begins to realize a pain of the character I have just mentioned to- 
gether with a feeling of weight or hard pressure as of a heavy body upon the 
left side of the chest, and in from a few minutes to an hour or two, increas- 
ing in severity until the patient appears extremely distressed. The pain 
centers in the cardiac region and radiates upward to the shoulder and 
sometimes down the left arm and not infrequently directly backward 
between the left scapula and the spine. The intensity of the suffering is 
accompanied by a sense of great oppression, causing an anxious expression 
of countenance, face generally pale, surface of the body cool, and not 
infrequently bathed in perspiration, extremities cold, pulse soft, weak and 



PATHOLOGY. 825 

sometimes quick, but more generally not faster than natural and occasion- 
ally intermitting. The respirations are very variable on account of thj 
intensity of the distress and sense of oppression in the chest, and the 
patient every few minutes takes a deep sighing inspiration or attempts to 
do so, which is sometimes defeated by the severity of the pain which 
arrests the expansion of the chest before its completion. The location of 
the pain centering in the cardiac region and sometimes radiating in the di- 
rections already named, the entire absence of febrile phenomena, the sud- 
denness with which the attack supervenes, with the extreme anxiety de- 
picted in the face, soft, irregular pulse, cold surface and extremities, are 
sufficient to characterize this form of disease and distinguish it from the 
painful affections of the stomach called gastrodynia and sometimes gastral- 
giaon the one hand, and from pleurodynia or pain in the intercostal spaces 
on the other. The paroxysms, as I have described them, continue very 
variable periods of time in different cases and in different attacks on the 
same patient. In the majority of instances the suffering begins to abate 
in about one hour, and frequently diminishes so rapidly that the patient 
is comfortable, though feeling extremely weak, at the end of another hour. 
There are some cases where it will be shorter, lasting not more than ten 
to fifteen minutes. There have been others in which it has continued 
with much severity for twelve, or even eighteen hours; and there are 
instances on record, although they are few in number, in which a severe 
and protracted paroxysm has terminated in the death of the patient. 
Patients who are subject to attacks of this disease suffer from them at 
very variable periods of time. In some cases they recur with some 
degree of severity almost every day or more than once in the day. But 
in the great majority of cases they recur only at intervals of from one to 
three or four weeks, unless in such cases as are liable to their recurrence 
at any time from particular motions or exercise. In some cases paroxysms 
are brought on at any time by attempts at active walking, going up stairs 
or any active muscular action. 

Pathology. — There can be little doubt but that the seat of this affec- 
tion is in the heart itself, or in the cardiac nerves; yet there are no 
uniform structural changes that can be detected by post mortem examina- 
tions that appear to be specially characteristic of this form of disease or 
to be the special cause of the paroxysms of severe suffering. In some 
instances the coronary ar'eries have been found ossified, in others there 
have been indications of gouty deposits and concretions in the coats of 
the arteries, instead of ordinary ossification. These have been patients 
who are either hereditarily or otherwise disposed to attacks of gout, and 
are suffering from the gouty diathesis. In perhaps a larger number of 
cases the only change that has been found after death is more or less fatty 
degeneration of the muscular structure of the heart, causing diminution 
of its muscular force, and consequently impairment of its ability to circu- 
late the blood. One writer has claimed that the disease consists in a 
spasm, or more or less tonic contraction of the coronary arterioles. That 
some influence of the kind may be exerted over the arterioles through a 
morbid condition of the vaso-motor nerves supplying them, is very 
probable during the paroxysms of this affection; but there is no proof 
that such is uniformly the case. There have been a large number of 
examinations, some of them very minute and reliable, of patients who 
have been subject to severe paroxysms of angina pectoris for years, and 
yet no structural lesions have been observed after death. And in those 
cases where the changes I have enumerated have been found after death, 
the history of each individual patient renders it evident that the changes, 



826 ANGINA PECTORIS. 

such as ossification of the coronary arteries, gouty deposits and fatty 
degeneration are rather coincidents, resulting from causes altogether in- 
dependent of the angina pectoris, and that they are simply coincident 
pathological conditions, instead of causes of that disease. From such 
cases as have come under my own observation, I am led to think that the 
immediate paroxysms of angina pectoris are caused by a morbid condition 
of the nerves supplying the vessels of the heart, and leading primarily to 
contraction of those vessels, lessening the supply of blood to the muscular 
structure, and inducing both pain and impairment of the force of the 
heart's action, and consequently developing the extreme anxiety, pain 
and depression that the patient endures. That ossification of the 
arteries, gouty changes, fatty and atheromatous deposits or any similar 
structural changes, by interfering with the natural action of the muscular 
structure as well as with the sensibility of the nerves, may predispose to 
the occurrence of angina pectoris, there can be no doubt; but their rela- 
tions to the disease are those of predisposing influences rather than patho- 
logical changes constituting a necessary part of the disease. 

Causes. — I have been led by clinical observation to the conclusion 
that the liberal use of tea, coffee, tobacco, and perhaps in a less degree 
alcoholic drinks, has a tendency more or less to favor the occurrence of 
angina pectoris in persons beyond the middle period of life, and especially 
as they approach what is called old age, or the period between fifty and 
sixty years; also sedentary habits, confinement in-doors, particularly if at 
the same time they are pursuing persistent and laborious mental occupa- 
tion. It is probable -that all these causes operate, not in directly inducing 
the painful affection called angina pectoris, but by interfering with the 
functions of respiration and digestion, and ultimately impairing the 
nutritive processes more or less, they lead to those structural changes I 
have already enumerated, especially such as fatty degenerations, impair- 
ment of the muscular force of the heart and perversion of nerve sensi- 
bility. These cause the patients to experience that weakness of cardiac 
action which renders them liable to attacks of pain on the supervention 
of any exciting cause, as undue exertion or imperfect digestion. And in 
many cases, after they have suffered a few attacks, they become liable to 
have them supervene, even without any special exciting cause. 

Prognosis. — The prognosis in any given case of angina pectoris must 
depend almost entirely upon the question whether any portion of the 
cardiac structures have undergone anatomical changes of a fixed or per- 
manent character. If the cavities of the heart are enlarged by dilatation, 
if the arteries have become more or less ossified, if gouty, fatty or athe- 
romatous changes have taken place in the muscular structure of the heart, 
as these are changes not usually capable of being removed, there is every 
reasonable probability that the paroxysms of angina will continue to recur 
on the occurrence of the slightest exciting cause during the remainder of 
the patient's life. But if on close examination, aided by careful physical 
exploration of the chest, no structural changes can be detected and the 
systolic action of the heart between the paroxysms, when the patient is at 
ease, have the natural degree of force and steadiness indicating that there 
is at least no decided weakness of the muscular structure from fatty 
degeneration, there is strong probability that the case may be conducted 
to a favorable termination, or in other words, that the patient may per- 
manently recover. 

Treat?nent. — As has been clearly indicated, the statements I have 
already made regarding the classes of patients subject to these attacks, 
and the influence of certain habits and pathological changes in per- 



TREATMENT. 827 

petuating them, lead directly to the inference that the painful paroxysms 
which constitute the affection we are considering' are symptomatic, i. e., 
not founded necessarily upon any fixed morbid conditions of the heart or 
structural changes. The treatment which demands the careful considera- 
tion of the physician is to be viewed in two relations: first, in relation to 
the means most efficient for the speedy relief of the patient during the 
paroxysms; second, the removal of the causes, when possible, including 
all habits and circumstances which would favor a return of the paroxysms. 
The one has for its object temporary relief, the other permanently secur- 
ing the patient exemption from a repetition of the paroxysms of suffering. 
At the present period of time, it is quite common to relieve the patient 
when the physician is called in the midst of a paroxysm, by immediate 
resort to the hypodermic injection of morphia. There is no doubt but so 
far as securing the temporary relief is concerned the hypodermic injection 
constitutes one of the most speedy methods. It is subject, however, to 
two serious objections. The first is the danger which is involved, 
especially in such cases as are accompanied by structural changes in the 
heart, of a character that greatly weakens or impairs its systolic action. 
When the muscular force of the heart is much impaired, especially by 
fatty degeneration, the sudden induction of the narcotizing effect of 
morphia is liable to be followed by fatal stupor. Especially is this true 
if the patient is unduly sensitive to the effects of opiates, or if the point 
of the syringe pisses in such a direction that it enters some small blood 
vessel, and consequently places the remedy at once in the blood and 
develops its effects with extreme rapidity. There is some risk that it 
may speedily suspend the sensibility and action of the cardiac nerves, 
and lead to immediate death. At least two cases of death under such 
circumstances have come within the circle of my own observation. This 
danger should certainly make you very cautious about the quantity of 
morphine introduced in this sudden manner. If it is resorted to at all, it 
is much better that the dose be too small for full relief, necessitating its 
repetition in half an hour or hour, rather than to risk the sudden develop- 
ment of the effects of a full dose at once, with perhaps an imperfect 
knowledge of the ability of the heart to carry on the circulation. And in 
addition to this, many patients who have no danger from structural dis- 
ease of the heart, nevertheless are uniformly susceptible to secondary 
nausea and severe sickness for many hours whenever morphine or prep- 
arations of opium are introduced sufficient to produce even a moderate 
anodyne effect, requiring sometimes one or two days for the stomach to 
regain its ability to retain nourishment. The patient is thereby caused 
more suffering in the aggregate than he would have endured during the 
brief period of the duration of the paroxysm if left alone. The second 
danger arising from the use of hypodermic injections of morphine consists 
in its tendency to speedily create the necessity for its repetition at shorter 
intervals. For, in almost all cases, while the direct effects of the mor- 
phine may relieve the patient at once, its frequent repetition so impairs 
the tone of the nervous system as to greatly increase that feeling of ex- 
haustion which alarms the patient, and causes him to become clamorous 
for its repetition on every threatened recurrence of the paroxysm. And 
hence it requires but a few months for the patient to become thoroughly 
habituated to the effects of the morphine and unwilling to be without 
it even for a day. It has the effect of leaving him with a sense of de- 
pression, goneness and weakness that makes him ex2eedingly uneasy 
until the anodyne effects of the remedy are renewed. That I am not 
giving you useless caution, is certain from the fact that I have seen cases 



828 ANGINA PECTOKIS. 

in wlrch the resort to hypodermic injections in this and similar nervous 
affections has led to the most serious disturbances on account of the de- 
velopment of a strong opium habit. In one of these cases it was actually 
carried to such an extent that the patient insisted on having one hypo- 
dermic injection in the morning and one in the evening every day, and 
it was not discontinued until mental derangement finaliy ensued, and 
it became necessary to remove the patient to an asylum for the insane. 
Therefore, if other remedies are a few minutes less speedy in their effects 
and less perfect in the direct relief they afford, it is better to use them 
and in the end, much to the advantage of the patient rather than to resort 
sd readily to the rapid introduction of morphine. As the gouty diathesis 
is not an infrequent accompaniment and in fact a predisposing cause of 
paroxysms of this disease, in such cases there is perhaps no remedy that 
can be administered by the mouth, that will afford more speedy relief 
than a combination of the acetated tincture of opium and the wine of 
colchicum root, equal parts, of which ten to twenty minims may be given 
in a little sweetened water, and repeated every thirty minutes till the 
patient is relieved. But if instead of the gouty diathesis with whicji you 
have to deal, the patient is one of those who, from much confinement in- 
doors or the habitual use of fermented drinks, has accumulated a large 
amount of fatty tissue with some degree of fatty impairment of the heart, 
one of the combinations most likely to relieve him from the distress 
of the paroxysm, is that of the tincture of digitalis, one part, and what 
is very generally known as Hoffman's anodyne, two parts, of which 
from twenty to thirty minims may be given and repeated every half hour 
till the patient is relieved. Quite a variety of antispasmodic, slightly 
stimulant and anaesthetic remedies, may be used for the relief of the 
paroxysms according to the circumstances and the convenience of the 
physician and his patient. In addition to the internal remedies, it will 
generally help to afford relief if a strong mustard sinapism is applied 
to the space between the left scapula and the spinal column, and another 
directly opposite on the left side of the chest, allowing them to remain 
until the skin is red, but not till blisters are actually raised, then remove 
ing them and substituting in their place cloths wrung out of water as 
warm as can be comfortably borne. But in many instances when the 
physician is called to these patients, the time which elapses before his 
arrival will be such that the paroxysm has already disappeared and he 
finds his patient comparatively comfortable. The question then is how 
best to accomplish the second object o.* the treatment, that is, to prevent a 
recurrence of the paroxysms in the future. It is entirely obvious to your 
own mind, from what I have said of the patients themselves and the 
variety of causes to which they may have been subjected, that no one 
remedy or combination of remedies can be recommended for this purpose. 
Here the great object to be accomplished is to ascertain whatever errors 
exist in the modes of life, habits of eating, drinking, exercise and dress, 
that would have a tendency to predispose to, and provoke these attacks; 
and to correct all such habits whatever they may be, and thereby remove 
the ordinary causes of the disease. If the patients are debilitated, the 
bowels inactive and the digestion enfeebled, it is highly proper to recom- 
mend such course of treatment as is calculated to obviate these several 
coincident conditions. Whatever will improve the general tone of health 
and render the processes and functions of the human body more natural, 
healthful and vigorous, will strengthen and tend to protect the patient 
from a recurrence of the paroxysms of this dreaded affection. It is par- 
ticularly desirable to have the patient avoid the too free use of strong tea 



EXOPHTHALMIC GOITRE. 829 

and coffee, and to rigidly abstain from all alcoholic beverages, either fer- 
mented or distilled, and to adopt such regular, moderate and daily out- 
door exercise by riding or moderate walking, as may be best suited to 
sustain the strength of the patient, promote the oxygenation and decar- 
bonization of his blood, and to sustain the functions of digestion and assimi- 
lation. At the same time it is quite necessary to give immediate attention 
also to the mental habits of the patient. All excessive mental application, 
either in studying, writing or any other process must be avoided. The 
occupation of the mind, like that of the body, should be sufficient to en- 
gage the attention, relieve the monotony of idleness, give the content that 
is derived from doing a little something every day, and yet there should 
be a careful avoidance of intensity of mental application or the entering 
upon such business as will bring anxiety of mind in regard to results. 



LECTURE LXXXVII. 



Exophthalmic Goitre— Fatty Degeneration of the Heart- Aneurism. 

GENTLEMEN: The assemblage of symptoms which has given origin 
to the name, exophthalmic goitre are met with not very frequently in 
ordinary practice, but they are sufficiently characteristic to merit separate 
consideration. As the words exophthalmic goitre would seem to imply, the 
three prominent symptoms characterizing all the cases belonging to this 
group, are enlargement of the thyroid gland, prominence of the eyeballs, 
and extraordinary or unusual action of the heart and the larger blood 
vessels, embracing particularly the aorta, subclavian and carotid arteries. 
It is most frequently met with in females, though not exclusively so. 
Much the larger number of cases occur between fifteen and thirty years of 
age; in most instances the symptoms are developed slowly, and generally 
the first to attract the attention of the patient is an unusual excitability of 
the heart. This causes throbbing or unusual pulsative action of the heart, 
extending to the vessels of the neck, in a less degree to the head, often pre- 
venting the patient for a time, if lying down at night, from going to sleep, 
and accompanied by more or less feeling of choking or tightness around 
the neck and upper portion of the chest; soon it is observed that the 
thyroid gland is decidedly larger than natural, giving the usual promi- 
nence to that part of the neck. This enlargement of the gland differs 
from that of ordinary goitre in being softer, more compressible, and being 
accompanied by a direct, plain, pulsation in the vessels of the gland. 
Usually in two or three months after the beginning of the cardiac ex- 
citability and the vessels of the neck become troublesome, it begins to be 
observed that the eyeballs are more prominent, or project forward more 
than natural. Generally there is at this time also more or less pain in the 
frontal region of the head, though not always; in some cases there is diz- 
ziness, sometimes ringing or noises in the head and ears and a disagree- 
able pulsation in the carotid and temporal arteries. When these patients 
lay the head down at night they are constantly annoyed by the un- 
usual pulsation and deterred from sleep. In young females, there is fre- 
quently an additional complication during the progress of the disease in 
the suppression of the menses. This does not always occur, but in 



830 EXOPHTHALMIC GOITRE. 

several instances coining under my observation, they have become en- 
tirely suppressed during the progress of the disease, adding much to the 
anxiety of the patients and their friends, and sometimes leading to altera- 
tions in the blood, indicated by the old name chlorosis. If no measures 
are taken to interfere with the disease, the eyeballs become remarkably 
prominent, giving a peculiar expression to the face, the thyroid becomes 
so large as to make a decided tumor upon each side of the neck, and in 
some cases extending across from one lobe to the other, and the vessels 
entering into it so much enlarged and pulsating, that it gives them many 
of the qualities of a large anastomosing aneurism. The vessels are capable 
of being emptied to a considerable degree, and the swelling reduced in 
size by steady pressure; but they fill again with a plain pulsating motion 
of the blood, and fully distend the tumor as soon as the pressure is re- 
moved. It is in this way that you can distinguish these enlargements 
of the thyroid from ordinary simple goitrous tumors or hypertrophy of 
the thyroid gland. The increased size of the thyroid, and consequent 
greater feeling of embarrassment about the neck, is accompanied bv a 
corresponding increase in the excitability of the heart, with a sense of 
fullness or vertigo in the head, which sooner or later so interferes with the 
movements of the patient as to cause almost entire confinement to the 
house, but seldom to the bed. There is usually no febrile heat accom- 
panying any part of the progress of these cases, unless from the acci- 
dental supervention of local irnflammatory action, not constituting a part 
of the disease proper. Physical examination by percussion usually elicits 
only negative results, there being no increased dullness over any part of 
the chest. Auscultation, however, pretty uniformly reveals a blowing or 
bellows murmur, both over the heart and over the course of the aorta up 
to the subclavian and carotid arteries, and frequently it is quite as loud 
and distinct over the vessels last named at the lower part of the neck as 
over the heart itself. The bellows murmur heard in these cases is free 
from roughness and harshness. It has none of the rough, harsh quality be- 
longing to the bellows murmer caused by valvular disease, and particularly 
by the indurated condition of the mitral valve so frequently resulting 
from acute rheumatic attacks. If the disease continues for a long period 
of time, the over-excitement of the heart leads in many cases to dilatation 
of its cavities with thinning of their walls. The disease has no definite tend- 
ency to a self-limited duration, although in a few instances of the milder 
grade, spontaneous recoveries have taken place; yet the great majority 
of cases are liable to persist through an indefinite period of time, and in a 
considerable proportion of them to develop such structural changes as to 
finally induce a fatal result. 

Causes. — The causes which give rise to this form of disease are so obscure 
as to have hitherto eluded any certain identification. 

Pathological Changes— In such cases as have terminated fatally, the 
heart and larger vessels have presented no uniformity in their morbid 
conditions. When the disease has existed for a number of years before 
the fatal result, the cavities of the heart have been found much dilated, 
the coats of the aorta affected by atheromatous degeneration, and the ves- 
sels of the thyroid greatly enlarged, as well as those in the posterior part 
of the orbit of the eye. Some observers have detected changes of a mor- 
bid character in the cervical gang.ia of the sympathetic nerve. The the- 
ory that the disease has its origin in a morbid condition of the vaso-motor 
nerves, or that portion of the nervous system ramifying in the coats of the 
vessels of the heart and of the large arteries in the chest and neck, influ- 
encing their functions in such a way as to favor dilatation of the vessels 



TREATMENT. 831 

and a yielding to the pressure of blood in them, coincidently with an in- 
crease of the excitability, is as plausible as any that has yet been proposed. 
But what particular influences are operating in most cases to induce such 
a change in the nerves, and consequent calibre of the vessels, is not appar- 
ent; clinical study having detected no uniformity in the influences that 
are traced as operating upon different patients sufficient to explain such 
results. 

Treatment. — The treatment in these cases, when commenced early, 
and pursued with a degree of patience and judiciousness will often re- 
sult in recovery of the patient. Bat it requires a considerable length of time 
and judicious adjustment of remedial agents, in connection with the hy- 
gienic management of the patient, to afford any chance of so favorable 
a result. The primary object in the treatment consists in such a regula- 
tion of the heart's action, as to lessen the morbid excitability of the ves- 
sels and reduce the flow of blood through them more nearly to the natural 
standard of quantity and frequency; in other words to bring to bear upon 
the heart and larger vessels such a sedative influence as will hold the 
cardiac and vascular excitability in check steadily through a considerable 
period of time. My own experience has led me to place more reliance 
upon a combination, or at least, coincident use of digitalis, Scutellaria and 
ergot, for the accomplishment of this purpose, than upon any other reme- 
dies. Several cases that have come under my care within the last few 
years have been greatly benefited by these agents, given in such doses 
and with such degrees of frequency as to develop the slowing influence of 
the digitalis upon the circulation, together with the tonic or contracting 
effect of the ergot upon the vascular system. If the bowels are inactive, 
suitable remedies should be prescribed for their regulation. If the kid- 
neys fail to secrete the usual amount of urine, diuretics should be added. 
Attention should be give n to the skin, and if inclined to be dry or defi- 
cient in eliminations, it should be subjected two or three times in the week 
to a warm bath, followed by frictions of flannel and the constant wear- 
ing of flannels next to the skin to protect the surface from sudden atmos- 
pheric changes, and keep the eliminations more uniform. The diet should 
be so regulated as to afford the patient sufficient plain, easily digestible 
food for a good degree of nutrition, and yet, all stimulating, indigestible 
materials should be carefully excluded. The regulation of exercise is also 
a matter of much importance. It is desirable that patients laboring under 
this affection should have invigorating outside air, but it is better that 
they obtain this by riding or by frequent short walks, than by any more 
protracted and severe exertion. Indeed, the latter should be carefully 
avoided. The patients should be encouraged to take much rest, and exer- 
cise but a short period of time continuously, either in-doorsor out, and to 
so regulate their business and movements as to favor quietude of the cir- 
culation, and as much freedom from excitement as possible. If the men- 
strual flow has either become scanty and pale, or interrupted altogether, 
this should not be entirely neglected in adjusting the treatment of the 
patient. In one instance recently under my care, in which the menses 
were suppressed, the patient appeared to derive much benefit from taking 
in addition to the digitalis, Scutellaria and ergot, a pill composed of thir- 
teen centigrammes (gr. ii) of gum guaiac, six centigrammes (gr. i) of sul- 
phate of iron, three centigrammes (gr. -J) of pulverized aloes, and two cen- 
tigrammes (gr. -J) of blue mass, of which one pill was taken after each 
meal time. The guaiac was given to encourage a return of the menstrual 
flow and to act as a general organic tonic. Another remedy, however, 
which is perhaps more generally recommended and used than any I have 



832 FATTY DEGENERATION OF HEART. 

named, is the application of electricity, or electro- magnetism. I have cer- 
tainly seen a number of patients greatly benefited, and two who appar- 
ently recovered, chiefly through the persistent use of electro-magnetism. 
The mode of application was to place the positive pole of a battery to the 
nape of the neck,or immediately below the occipital region, and the other at 
different points from the lower part of the neck to the ensiform cartilage, 
in making the currents gentle, simply sufficient for the patient to feel 
their influence, and avoiding all shocks or severe disturbance, and con- 
tinuing the electric influence from ten to fifteen minutes each day. 
Sometimes the mode of application was varied, the patient taking one pole 
in each hand, and allowing the current to pass in the usual way from one 
hand, through the trunk of the body to the other. More frequently, how- 
ever, when extending the application a distance from the back of the 
neck and the region of the sternum, I have kept one pole below the occi- 
put in the upper part of the neck and placed the other at the bottom of 
one of the feet; and in a few instances I have varied the use of the elec- 
tricity in such a way as to charge the patient's system with the electric 
fluid by insulating her upon an insulating stool. To make these or any 
other remedies effectual in the treatment of this form of disease, each 
patient must exercise patience and perseverance, both in the application 
of the remedies and in the general hygienic management, as I have al- 
ready indicated. 

; Fatty Degeneration of the Heart. — I shall detain you only for a few 
words in regard to fatty degeneration of the heart. It is a condition 
'which usually results from the slow and long continued defective oxygena- 
tion and decarbonization of the blood. When once fairly established it 
creates that weakness of cardiac action which greatly embarrasses the 
patient whenever attempting to take active exercise. Most patients sub- 
ject to this condition of the heart, whenever quiet, either in the recumbent 
position or in the sitting posture, enough inclined to be at ease, are hardly 
conscious of the existence of any embarrassment. But they have no 
power of endurance. A very moderate attempt at exercise, as inordinary 
walking, particularly ascending hills or going up-stairs, causes extreme 
rapidity of the circulatory movements, accompanied by a sense of oppres- 
sion, or weakness across the chest, and such a degree of mental anxiety 
as usually induces the patient speedily to seek a position of rest. A soft, 
weak, slightly accelerated pulse, diminution of the impulse of the heart in 
the cardiac region, shortness of the systolic action, and the inability to 
exercise, constitute the symptoms most characteristic of this form of 
trouble. The best mode for its management consists in inducing the pa- 
tient to so regulate his diet as to avoid all indigestible articles, and yet 
secure a sufficient supply of food to afford a fair degree of nutrition; to 
take food at such times in the day that digestion is always completed be- 
fore the time for sleep at night, and to avoid all severe physical exertion. 
Yet the patient should obtain, either by riding, or very short and quiet 
walks, more or less of out-door exercise daily. Patients laboring under 
this condition of the heart, when not subject to paroxysms of angina pec- 
toris, or any other special complication, are nevertheless easily tired, and 
readily exhibit a relaxed condition of the skin, with perspiration sufficient 
to keep the surface damp, and sometimes even to dampen the underclothes, 
and of course whenever exposed to currents of air feeling at once chilly, 
and morbidly sensitive to atmospheric changes. They not only become 
weary from trifling exertion, and short of breath, but they are subject to 
a great sense of weakness across the chest, and anxiety, as though stop- 
page of the heart's action was immediately pending. This impression is 



TREATMENT. 833 

added to by the occurrence, with many of the patients, of irregularity in 
the movements of the heart, consisting of two, three or four systolic beats 
or contractions in quick succession, then stopping perhaps long enough to 
omit one beat, and resuming anew, with a short and distinct interval; 
then a variation to the irregular, rapid, systolic movement, and then a re- 
turn as before to a slower, and sometimes intermitting condition. The 
heart and the pulse thus become weak, variable, and sometimes intermit- 
ting. 

Treatment. — The treatment of this class of cases consists mainly in the 
proper regulation of the patient's exercise, diet, habits, mental and physical, 
in such manner as to avoid, as far as possible, undue excitement, and too 
great an amount either of mental application or of mental worry and 
fatigue. The anatomical changes resulting from fatty degeneration are 
in most cases a slow atrophy or thinning of the walls of the heart, with 
corresponding enlargement or dilatation of the ventricles. It is this kind 
of disease of the heart that renders patients most liable to sudden death. 
For as the muscular structure becomes more and more degenerated, and 
consequently has less and less contractile power, with some degree of dil- 
atation of the ventricles, it arrives at a stage of weakness, when at the 
moment of some moderate degree of exertion, as in rising from bed or in 
taking up some moderate weight and carrying it a few steps, the heart 
cavities fill with blood, their walls fail to contract, the heart stops in dia- 
stole, and the patient dies instantly, exhibiting paleness of features, or an 
almost bloodless condition of countenance and conscious only of a reeling 
in the head and dimness of vision as they sink to the floor. As the heart 
first ceases to act these cases have been called death by syncope. As I 
have just said, the leading objects in the treatment of these cases are to 
regulate properly the patient's habits, mental and physical, and to admin- 
ister such remedies as will increase the force and lessen the frequency of 
the cardiac action and arrest further molecular degeneration. Digitalis, cac- 
tus and convallaria are perhaps the three remedies on which we can rely 
more than on any others to increase the force, lessen the frequency and 
thereby render more efficient the circulation of the blood. The doses of 
these remedies must be apportioned to the age and condition of the pa- 
tient, in beginning with moderate doses, and gradually increasing until 
the pulse becomes slower and more full, then recede a trifle, aiming to 
continue the influence without causing; it to become exaggerated. In cases 
accompanied by much general deposit of fat throughout the system, I have 
thought that the patients derived positive benefit by taking from three to 
six decigrams (gr./V to x) of the chlorate of potassium in dilute solution 
with mucilage of gum arabic and water after each meal. The increase of 
the chlorine salt in the blood, when thus administered, I have reason to 
think is capable of increasing the amount of oxygen taken up from the air 
cells of the lungs, and consequently of increasing the oxygenation and de- 
carbonization of the blood, and in the same proportion checking the prog- 
ress of the tissue degeneration. Consequently, when the stomach and 
bowels will tolerate moderate doses of the chlorate, administered in this 
manner for a considerable period of time, it is capable of doing much good. 
If the appetite is poor, adding a few drops of hydrochloric acid to each 
dose of the solution of chlorate of potassium will frequently improve the 
appetite and render the digestion of food more active and complete. 

Aneurisms. — Aneurisms are usually classed with surgical diseases, and 
treated of fully in surgical works; and yet the management of aneurisms 
located upon the heart or aorta are usually entirely beyond remedy by 
surgical means, and are consequently left generally for the management 

53 



834 ANEURISMS. 

or palliation of the ordinary medical attendant. You will, therefore, some- 
times be required to take charge of, and endeavor to counteract the prog- 
ress of this class of affections. For a full discussion of aneurisms of the 
heart and aorta, I must refer you to surgical works, and will only detain 
you for the purpose of suggesting a few simple rules in regard to the best 
modes for their management. When fully formed, there is but little hope 
of cure. A true aneurismal tumor or dilatation of any portion of the walls 
of the heart, of the coats of the aorta or larger blood vessels connected 
with it, neither admits of being treated by surgical operation on the one 
hand, nor, on the other hand, are there known any means or agencies of a 
medicinal character capable of contracting these dilated pouches or an- 
eurismal sacs, and restoring them to their natural condition. If you coag- 
ulate the blood in them by astringent injections or otherwise, you incur 
the great risk of having portions of the coagulum carried as emboli into 
the vessels of the brain or lungs and producing speedy death. There is 
also risk of ulceration at the point of puncture, and fatal hemorrhage. Yet 
judicious management of such cases may greatly increase the strength ot 
the patient, retard the natural increase in size of the aneurism, and con- 
sequently materially prolong the life of the patient. To accomplish these 
results all patients afflicted with aneurism of the heart or great vessels in 
the chest should be instructed to avoid all active exercise, sudden exertion, 
or active manual labor, and yet they should be encouraged to take a mod- 
erate amount of quiet out-door exercise either by riding or moderate walk- 
ing every day. To render life useful, occupy the attention, and thereby 
relieve them from misanthropy and continual dread, they may be en- 
couraged to engage every day m some light occupation, or attending tc 
any business that can be done by riding, and yet the mind should not be 
over-tasked or rendered anxious on account of pecuniary results. The 
clothing should be strictly adjusted for comfort to the seasons of the year 
and climate, attention should be given to all the various functions, with a 
view to keeping the digestive organs in as perfect order as possible, and 
the secretions and eliminations at their natural standard of activity. In 
addition to this, the direct treatment on account of the aneurism should 
consist in the administration of such remedies as will lessen the force and 
frequency of the current of blood, filling the aneurismal tumor, as far as it 
can be done, without seriously debilitating the patient. For this purpose 
the use of the well-known arterial sedatives judiciously adjusted, consti- 
tute our greatest reliance. In former generations, copious bleeding was 
resorted to with the idea of lessening the fullness of the vessels and con- 
sequently encouraging contraction or lessening of the aneurismal sac. 
This, however, is productive of no benefit except in some rare cases, where 
the general condition of the patient is one of actual plethora. In such a 
case the abstraction of just enough blood, once or twice in the year, to re- 
move any excess or positive plethoric condition might be desirable. Few 
patients, however, laboring under aneurismal disease, possess any such 
plethoric condition. But the doses of digitalis, veratrum viride, aconite, 
gelseminum and perhaps convallaria, can usually be so adjusted as to suit 
almost all classes of patients, and keep sufficient sedative influence upon 
the heart, to greatly promote the comfort of the patient and prolong 
his life. When the habits or temperament of the patient has been such as 
to encourage fatty or atheromatous degeneration of the walls of the vessels, 
three decigrams (gr. v) of the iodide, or six decigrams (gr. x) of the 
chlorate of potassium, given after each meal time, in a wine glass full of 
sweetened water or of mucilage, will, in some cases at least, do much good. 



DERANGEMENTS OF DIGESTION. 835 



LECTURE LXXXVIII 



Functional Derangements of the Stomach and Organs of Digestion— Their Nature and Treatment. 

GENTLEMEN: The words dyspepsia, indigestion and constipation, 
though in very common use to indicate a class of functional disorders 
of the stomach and alimentary canal, nevertheless indicate no one special 
pathological condition. They are derived from the prominent symptoms 
rather than, from any particular relation to the morbid conditions on 
which these symptoms may depend. As you perceived while listening to 
the discussion of the subject of gastritis in its various grades, indiges- 
tion was one of the more prominent symptoms accompanying one of the 
forms, or grades of that disease. And as we have already discussed fully 
that subject, including gastric hyperemia, and hyperesthesia, we have 
now only to consider that large and almost constantly recurring class 
of cases, in which the prominent symptoms are imperfect digestion of 
food, arising from conditions independent of local inflammatory action. 
Leaving out of view all grades of the latter, we may still have perhaps 
three distinct and recognizable conditions of the stomach, more par- 
ticularly of the structures entering into the composition of the mucous 
membrane, which, though giving rise to the common symptoms of im- 
perfect digestion of food, accompanied by more or less distress to the 
patient, are essentially different in their nature, and require different 
methods of treatment. Proper nerve sensibility, the normal amount and 
quality of the gastric juice, and the proper muscular motion of the 
stomach, are the three essential requisites for the performance of healthy 
digestion. It follows then, that a failure of either of these three would 
be likely to derange the process, and lead to imperfect results, sufficient 
to inconvenience or distress the patient. A close examination of patients 
will enable you to distinguish cases depending upon each of these three 
derangements separately, but perhaps more frequently cases, that depend 
upon the coincidence of two of them at the same time. The coincidence 
of defective secretion of gastric juice with insufficient peristaltic motion 
constitutes the most common condition of ordinary indigestion, especially 
in patients of sedentary habits, or who are much confined by their occu- 
pations, in-doors. The alterations of nerve sensibility, as a source of de- 
rangement of digestion, is of less frequent occurrence, and yet, there are 
some cases depending upon this cause, and if not recognized, they are 
very liable to be protracted in duration and exceedingly troublesome, both 
to the physician and patient. The alterations of nerve sensibility may be 
either reflex, as when derived directly from morbid conditions in the 
nervous centers from which the nerves concerned in the functions of the 
stomach are derived, or in the gastric nerves alone. You are aware that 
in addition to a supply of nervous filaments from the vaso-motor, or 
ganglionic system, an important supply comes also through branches 
of the pneumogastric, connecting the mucous membrane of the stomach 
directly with the brain, and constituting the medium through which im- 
pressions may be transmitted from the cerebral centers to the stomach, or 
the reverse. That conditions of the brain, as to excitability, or the activ- 
ity of mental processes, are capable of radiating an influence through 
the pneumogastric nerves upon the secretory structures of the stomach 
sufficient to produce marked alterations in the secretions, both in regard 



836 DERANGEMENTS OF DIGESTION. 

to their quantity and quality, is easily illustrated by investigating the 
effects of strong mental emotions, passions, or even of intense and con- 
tinuous intellectual activity, soon after taking food. Nothing has been 
more fully determined than that these conditions are extremely liable to 
arrest the digestion of food, lead to its fermentation, and all the phenom- 
ena of a severe paroxysm of indigestion. It is on this account that per- 
sons engaged in intellectual pursuits, including those who are engaged as 
accountants and book-keepers, who are in the habit of resorting to their 
work immediately after their meals, are so very liable, in a few years and 
sometimes in a few months, to become habitually troubled with indiges- 
tion. But there is another and different condition of the gastric nerves 
which interferes with digestion, namely, a true hyperaesthesia of the 
nerve filaments, rendering the membrane so sensitive that food, when 
taken, will not be retained, but rejected almost as soon as it is swallowed. 
There is no appearance of gastric inflammation, nor any quickening of the 
pulse, tenderness over the epigastrium, nor any of the symptoms that 
usually indicate inflammatory conditions, not even a reddened condition 
of the tip, or edge of the tongue; but in the absence of all these, a 
degree of morbid sensitiveness, the prompt rejection of food within a very 
few minutes after it is received into the stomach with hardly a conscious- 
ness of nausea, and usually, in the same condition in which it was origi- 
nally taken, without having undergone either digestion or fermentation. 
Such cases are not of frequent occurrence, and yet I have met with a con- 
siderable number of them during my clinical experience. Such patients 
take food with apparent ease, but hardly have time to more than turn 
away from the table before they eject it in the same condition in which it 
had been swallowed; and they sometimes feel a decided disposition to 
turn back and eat as much more. If they do, it is usually ejected in the 
same manner. Such persons, by taking a very small quantity, will some- 
times retain it, and it is probable that they rarely reject all the food they 
take at any one time, because few of them really become emaciated. I 
have seen some instances where the patients would thus promptly reject a 
large part of the food after almost every meal for months, and yet lose 
but little flesh, and exhibit but little indication of anaemia. I need not re- 
mind you that the vomiting so frequently observed during the early 
months of pregnancy, is reflex in its character from irritability in the 
nerves of the uterus being transmitted to the nervous centers, and from 
there reflected upon the stomach. And in many of the acute diseases, 
particularly inflammations involving the nervous centers, unusual vomit- 
ings are among the first symptoms to attract attention. 

The best mode of managing reflex cases of indigestion, is to carefully 
ascertain the habits and influences affecting the patient's daily life, with a 
view of ascertaining if possible the causes and circumstances which have 
induced the morbid sensibility of the gastric nerves. If there is any focus 
of irritation in other viscera that reflects a disturbing influence upon the 
base of the brain, or origin of the pneumogastric nerves, and through 
them upon the stomach, so far as possible the primary seat of irritation 
must be relieved before permanent relief of the gastric symptoms can be 
expected. If the source of morbid sensitiveness is in the brain itself, 
whether derived from intense mental application, or indulgence of the 
emotions and passions, particularly during the first stage of digestion or 
soon after eating, or any other cause capable of producing undue deter- 
mination of blood to the brain — these conditions must be ferreted out and 
corrected, as a necessary part of the treatment, if relief of any perma- 
nent character is to be obtained. It is a good rule for every person to 



TREATMENT. 837 

avoid engaging in intense mental work for the first half hour after taking 
an ordinary meal, and if possible to spend that time either out of doors 
or where they have a full access to fresh pure air. It is well known 
from physiological experiments, that oxygen is taken up from the air cells 
of the lungs very much more rapidly during the first hour after taking an 
ordinary meal, while digestion is going on actively, than at any other 
period of time. This would indicate that the patient during such time, or 
the early part of digestion, should have the freest access to pure air, and 
that the process of breathing should be untrammeled, accompanied by 
light physical exercise or mental diversion. 

There is no doubt but the observance of this simple rule in regard to 
leaving the mind habitually in a state of ease, with a full, free access of 
air during the first half or three quarters of an hour after taking an ordi- 
nary meal, would prevent a very large amount of imperfect digestion of 
food, and save a great many individuals from becoming confirmed 
invalids through imperfect digestive processes. When this rule has 
been habitually violated and patients are suffering from indigestion 
in consequence, it is in vain to endeavor to cure them by drugs or 
do anything more than simply to palliate some of the more promi- 
i.ent symptoms from time to time, unless the rule is enjoined, and 
it is literally complied with. In regard to medicine for the class of 
cases dependent upon pure morbid excitability of the nervous structures, 
it is desirable to select and use some agent calculated to produce as direct 
a soothing or sedative effect upon the sensibility of the nerves involved, 
as is possible. The best time to make an impression is immediately before 
taking food. In some instances I have obtained very prompt and entire 
relief by giving, just before the patient sits down to take his meals, six 
decigrammes (gr. x) of bromide of potassium with the same number of 
minims of the fluid extract of hyoscyamus in a tablespoonful, or four cubic 
centimeters of water. The bromide and hyoscyamus in many such cases 
when taken just before taking food, coming in contact with the sentient 
nerves of the mucous membrane, produce their full sedative effect, lessen- 
ing the nervous excitability, and by absorption and diffusion extend some 
of the same soothing or calming influence over the whole central portion 
of the nervous system. If, as sometimes happens in these cases, there is 
some tendency to fermentation, causing the formation of gases and eructa- 
tions, the addition of small doses of carbolic acid to the bromide and hy- 
oscyamus will increase the efficacy by acting as an antiseptic. It is also 
modjrately sedative to nerve excitability and therefore makes a valuable 
addition to the other two ingredients. In the same class of cases moder- 
ate doses of hydrocyanic acid, taken in mucilage of gum arabic, have also 
frequently succeeded in removing the undue sensitiveness and causing 
the food to be retained and assimilated. As I have said before, the 
krger number of cases of ordinary indigestion, as they are met with in 
rr.ictice, depend upon the coincidence of defective secretion of gastric 
juice with impaired peristaltic motion, not only of the stomach, but 
of the whole alimentary canal, and causing the indigestion to be associated 
with more or less habitual constipation. This condition isof very frequent 
occurrence in modern society amongall classes who arenot engaged freely 
and abundantly in physical exercise out-doors, but more especially common 
among the female sex, who in addition to being much in-doors and neglect- 
ing active ordinary exercise on foot in the open air, also by their modes 
of dress confine the chest in such a way as to limit the habitual expansion 
of the lungs, and the consequent consumption of oxygen and the elimina- 
tion of carbonic acid gas. By the coincidence of in-door life, little phys- 



838 DERANGEMENT OF DIGESTION. 

ical exertion, and daily restricting the function of respiration so as to 
make the amount of oxygen consumed and carbonic acid eliminated a few 
cubic inches below the normal standard, the blood is caused to circulate 
through the whole arterial system, holding in solution an excess of certain 
effete constituents, especially carbonic acid gas, which is a direct sedative 
to nerve sensibility, and a deficient supply of oxygen as an excitant both 
of nerve sensibility and muscular contractility. The inevitable result of 
such a condition, continued for any considerable time, is the impairment 
of the tone of the whole muscular system, voluntary and involuntary, in- 
cluding such as constitute the muscular coat of the stomach and intestines 
equally with those of voluntary motion, and of the susceptibility of the 
whole nervous system, both central and peripheral. One of the conse- 
quences is an impairment of the involuntary muscular movements, includ- 
ing, particularly, those of the alimentary canal throughout its whole course. 
Persons of this class consequently seldom arrive at the middle period of 
adult life before they have developed both habitual constipation, and im- 
perfect digestion of food. The food, though taken with a moderate ap- 
petite, is found to lay simply like a load, or dead weight, in the epigas- 
trium after eating. Sometimes this is so marked as to be described as 
feeling like pieces of lead in the stomach. This dull, heavy feeling is ac- 
companied by more or less general feeling of fullness and depression, and 
not infrequently, mental despondency. In many cases it is not felt per- 
ceptibly until about half an hour after eating. Then it gradually increases, 
the load and sense of fullness become more and more uncomfortable, un- 
til in from one to two hours there is added the liberation of gases; and 
what was previously a simple feeling of heaviness, now becomes a very dis- 
tressed feeling of distension in the epigastrium until the gases begin to be 
belched up, generally in large quantities. After belching up quantities of 
gas, in most instances tasteless and odorless but sometimes having more 
of a nauseous and offensive quality, the feeling of uneasiness passes off, 
and the patient becomes comparatively comfortable till about the same 
hour after the next meal. And thus he passes day after day, month after 
month, suffering about the same length of time after almost every m al 
that is taken. Perhaps, in a majority of cases, the symptoms are simply 
those I have described, accompanied by constipation. But there are 
some in which there is not only a fermentation which results in the libera- 
tion of large quantities of gas, but more or less of acid also. And then 
you meet with eructations of a sour or acrid character. If so, there is usu- 
ally added at the same time more or less of, burning sensation, or what 
is popularly called heartburn, and sometimes gastralgia. 

In these cases there is usually a light degree of actual hyperemia, or 
approach to an inflammatory condition of the mucous membrane, but so 
slight that it passes off as soon as the stomach becomes again empty. It 
is a very common practice to supply this class of patients with palliatives, 
including every variety of antacids, antiseptics, and sometimes stimulants, 
with a view of either preventing the formation of gases, which are sup- 
posed to be the chief cause of the patient's misery, or facilitating their ex- 
pulsion when they have been formed. At the same time the constipa- 
tion of the bowels is also very apt to be regarded as the evidence of 
biliousness, and every few days the intestines are emptied by an active 
dose of physic; but just as often they lapse back into the same inactive 
condition as they were in before the physic was taken, when another dose is 
resorted to. Hence such patients follow up the routine of taking all the 
varieties of pepsin, charcoal, alkalies and carminatives, interspersed with 
active physic, every two or three days, for months and sometimes years. 



TREATMENT. 839 

Such management, however, has no other result than that of simply palli- 
ating symptoms, but does nothing toward removing the pathological 
conditions from which the patient suffers, or the causes which have led to 
them. No beginner in the practice of medicine can take a better direc- 
tion for ingratiating himself into the favor of a large number in the com- 
munity, and laving the foundation for a popular practice, than b\ a care- 
ful study of this class of cases of ordinary indigestion and constipation, 
with a view of understanding clearly their causes and the pathological 
conditions they involve, that he may, whenever he comes in contact with a 
case, be able to put the patient upon such a course of correct habits of 
life, and such aid from well-directed remedial agents, as will give him a 
more permanent and satisfactory restoration. Such cases are curable 
with only a moderate use of medicine, provided the patients will adopt 
proper habits of life and avoid the causes which have produced them. 
Nearly all of this class of cases depend entirely on the two pathological 
conditions I have mentioned, namely, defective muscular or peristaltic 
motion of the stomach and bowels and the coincident deficiency in the 
secretion, both of the gastric juice and of the ordinary mucous from the 
follicles of the intestines. And the causes which have led to it, are in a 
very large majority of the cases, the coincidence of deficient out-door ex- 
ercise, and either habits of dress or occupations that help to limit, or em- 
barrass the free exercise of respiration, and thereby lessen the oxygena- 
tion and decarbonization of the blood. If to deficient exercise, and in- 
efficient breathing, there is added constant mental application, it will 
hasten the development of evil consequences. The rational treatment of 
such cases is so plain that I hardly need take time to mention it in detail. 
It involves the correction of erroneous habit-, as essential to its per- 
manency. It is not difficult to temporarily relieve such patients, but for 
permanent relief, the causes which contribute to the development of the 
morbid conditions must be absolutely avoided. Consequently, exercise 
to a moderate extent in the open air at some part of every day, the ex- 
ercise of the chest in such a way, daily, as to promote absolute full, free, 
efficient respiration, sleeping in well- ventilated rooms, the use of plain 
diet, the avoidance of all anaesthetics, like alcoholic drinks, and much bet- 
ter, if it include also avoidance of tobacco, are absolutely essential parts 
of the treatment of all cases where any permanent results are expected. 
There are not many patients but who, if the necessity for this part of the 
treatment is pointed out clearly, will sooner or later yield obedience to 
the requirements, although they may, if engaged in particular lines of 
business, protest at first that they have no time to do it. But there is no 
proper business in the world, and should be none engaged in by individ- 
uals anywhere, that does not leave, if time is properly economized, op- 
portunities every twenty-four hours for taking the exercises which are 
needed for the class of patients under consideration. 

If there are any exceptions to this rule, they are to be found among the 
poorer mechanics and artisans, whose work is habitually within doors in 
some confined position, and who must extend their hours to the utmost 
limit, to keep the poor family from suffering for the necessaries of life. But 
then they are rarely required to be at their labor earlier than seven in the 
morning, and usually at home as early as six in the evening, thus affording 
time both before commencing in the morning and still greater time in the 
evening before going to bed, to counteract much of the evil effects of the 
day's confinement by judicious exercise, in such manner as may be pointed 
out to them. I wish you not to forget that the exercise which is most valu- 
able and most needed for promoting elimination of waste material, more effi- 



840 DERANGEMENTS OF DIGESTION. 

cient oxygenation of the blood, its diffusion through the whole vascular sys- 
tem, and consequently the establishment of its influence over the functions 
of the body, does not consist mainly in mere walking, but involves, neces- 
sarily, daily exercise of the arms and muscles of the chest sufficient to keep 
the muscles concerned in ordinary respiratory movements in a vigorous and 
healthy condition. Having dwelt thus emphatically upon the portion of the 
treatment which relates to the hygienic management of the patient, which 
is really the most important of all, it only remains to study those remedial 
agents best adapted to such cases, and select such as will possess two dis- 
tinct properties; one a tonic of such character as is calculated to increase the 
efficiency of the nervous and muscular actions concerned in the movements 
of the stomach and intestines, and with these just sufficient laxative to pro- 
mote a single natural movement of the bowels once a day, without ever 
acting as a cathartic. If you can select from your materia medica any 
combination of agents that will present to the organic nervous system a 
tonic such as is calculated to increase the innervation and nerve sensibil- 
ity, you will thereby increase the muscular contractility and movements, 
and with this such a laxative for a time during the early part of the treat- 
ment as will simply suffice to prompt a single movement of the bowels 
each day, you will in one week be able to so far correct the faulty action 
of the digestive organs as to have well-nigh established exemption from 
the prominent symptoms of indigestion which had previously tormented 
the patient. My remarks now in reference to remedies, as you will 
notice, include those most efficient and desirable for the removal of habit- 
ual constipation, as well as indigestion. 

For a long period of years, I have been in the habit of prescribing for 
this class of patients a combination of the extract of hyoscyamus, sulphate 
of iron, aloes and nux vomica or strychnia, usually in the form of a pill. 
In prescribing for an adult, a pill containing six centigrammes (gr. i) 
each of the extract of hyoscyamus and sulphate of iron, and two centi- 
grammes (gr. J) each of pulverized aloes and extract of nux vomica may 
be given before each meal, and if the patient is laboring under a very 
decided degree of constipation, another at bed time. And if, as sometimes 
happens in these cases, there is a yellowish coat upon the tongue, the 
urine a little redder than natural, and when cool ; throwing down a whitish 
phosphatic or ammoniacal sediment, it will be profitable to add two cen- 
tigrammes (gr. ^-) of blue mass to each of these pills. In many instances, 
giving these pills as I have indicated, there will be no direct effect in 
moving the bowels during the first two days. But if the patient does 
not resort to other physic by the third day, there will almost invariably 
occur an evacuation, which with a majority of patients will be costive, 
requiring some effort as usual to void it, especially at the beginning of 
the evacuation. Continuing the same number of pills, the bowels will 
move again the next day, but a little easier. The day following most 
patients will have two evacuations, showing the influence of a laxative. 
My rule is, to give definite instructions that so soon as the effects develop 
more than one easy natural movement a day, one pill is to be omitted, 
usually the one before dinner, allowing the patient to continue the one 
before breakfast, at tea time, and bed time. With many this will be 
found not merely to perpetuate one single movement a day, but after a 
few days to make the bowels a little more loose, and another pill can be 
dropped, leaving only one morning and evening; and still later another 
may be omitted, leaving but one to be taken every night. The great 
majority of such patients, by the end of the third week from the time they 
commence, will have an entirely regular, healthy condition of the aliment- 



TREATMENT. 841 

ary canal, with little or no trouble from indigestion while using only one 
pill each d:iy. It is better that they continue this for a considerable 
time, but ultimately the}' can diminish this to one every second evening, 
and finally to once in three days. Then they can drop-it entirely for a 
week or more at a time. After this it will be sufficient to follow the rule 
to take one pill at bod time whenever there has been no evacuation dur- 
ing the preceding twenty-four hours. 

An additional item of much importance, is, that the patient maintain a 
strictly regular habit of going to stool at some given hour each day. 
Usually the best times to go are immediately after breakfast in the morn- 
ing, or immediately before going to bed. A majority of patients will 
succeed best by going immediately after each morning meal. Proper at- 
tention to the hygienic measures I have indicated, combined with treat- 
ment by medicine on the principle I have clearly laid down, will succeed 
in ninety-nine cases out of a hundred in relieving this class of patients both 
of indigestion and habitual constipation. But there are at least a score 
of remedies and combinations that may be made from the tonics, espe- 
cially of the class of nerve tonics, and such mild laxative remedies as are 
familiar to every student of the materia medica, besides those entering 
into the pill I have indicated. In those cases of indigestion presenting 
in addition to the mere load in the stomach and distension from the gen- 
eration of gases, there is manifest during the process of digestion some 
sourness or acidity rising from the stomach, indicating acid fermentation, 
I have derived much greater benefit by giving patients a teaspoonful, or 
four cubic centimeters, of a combination I have often mentioned during 
this course of lectures, as the carbolic acid mixture. It contains carbolic 
acid, tincture of gelsemium, and camphorated tincture of opium in proper 
proportions, with a little glycerine and water.* Four cubic cen- 
timeters, (fl. 3i) or a teaspoonful of this mixture in a tablespoon - 
ful of water taken immediately before the patient commences to eat, at 
each meal time, will have an important influence in correcting the process 
of fermentation, and greatly lessen the inconvenience that the patient suf- 
fers during the stomach digestion. Of course it will do nothing toward 
removing constipation and maintaining the natural muscular action of the 
stomach and bowels. To accomplish this, where I use the carbolic acid 
mixture before each meal, I direct at the same time a pill consisting of 
six centigrammes (gr. i) each of the extract of hyoscyamus, sulphate of 
iron, aloes and blue mass, with two centigrammes (gr. ^) of extract of 
nux vomica, and allow this pill to be taken when the patient retires to bed 
at night. By this increase of the amount of aloes and blue mass to each 
of the pills previously mentioned, I have aimed to make them active 
enough for one pill taken at night to prompt the necessary movement of 
the bowels the next morning. 

During the last ten years I have relieved, more satisfactorily and fully, 
a majority of cases of ordinary indigestion coupled with constipation of 
the bowels, by this process of giving the carbolic acid mixture immediate- 
ly before taking food, and a tonic and laxative pill at bed time, than by 
any other means. But by no means, gentlemen, get the idea that either 
this or any of the formula I have given you are essential in the treatment 
of such cases. On the contrary, any combination you may make that does 
not contain a positively irritating material, and that will on the other 
hand act as a genuine tonic to the nervous and muscular structures 
entering into the alimentary canal, and will also gently promote the 

* See page 138. 



842 DERANGEMENTS OF DIGESTION. 

secretions of the gastric and intestinal glandular structures, with the 
proper regulation of the patient's habits and modes of life, will afford re- 
lief in almost all this numerous class of cases. After alluding to these 
general principles in regard to the treatment of the different forms of in- 
digestion and constipation, I need not take up more time, but leave each 
one to his individual judgment and tact, in selecting the special remedies 
to fulfill the indications I have endeavored to point out. There are, 
perhaps, two painful conditions of the stomach, that are liable to occur 
more or less in connection with all grades of indigestion, about which 
a word or two should be said. I allude to gastrodynia, or pain in 
the stomach, and cardialgia, or burning in the stomach, but more 
popularly styled heart burn. The latter is almost always dependent 
upon either the generation of acid in the stomach, or a certain degree 
of inflammatory action. When the latter, it is best treated, as I 
have already pointed out to you when speaking of the forms of 
gastritis. When dependent upon acid, the remedies that may relieve 
temporarily are the «antacids, alkalies, alkaline earths or substances capa- 
ble of neutralizing an acid. Bicarbonate of soda, calcined magnesia, 
carbonate of magnesia used by themselves, or in solution and associated 
with some carminative, as cardamom, anise, or mint water, will usually, if 
given in moderately liberal doses, speedily neutralize the excess of acid 
and after giving rise to the formation and eructation of gases, relieve the 
distress of the patient. Of course this refers only to the paroxysms. If 
associated, as it generally is, with one of the forms of indigestion that I 
have already alluded to, permanent relief, or the prevention of the re- 
currence of such paroxysms will depend upon the removal of the patho- 
logical condition involved in the case. 

Gastrodynia is a term applied, not to the ordinary sensation of un- 
easiness, load or burning in the stomach, but a distressing pain in the 
epigastrium, and often radiating upward behind the sternum, reaching 
as high as the lower part of the neck, and not unfrequently involving 
the sensation as if there was a great weight or pressure upon the whole 
anterior part of the chest, with an extraordinary intensity of pain directly 
in the epigastrium, yet at times also radiating backward, and becoming 
almost as intense in the central part of the dorsal portion of the spine as 
in the epigastric region itself. Most of such attacks are accompanied by, 
if not directly dependent upon, a rapid generation of gases, and disten- 
sion of the stomach. In some rare instances the stomach,"at least for the 
time being, seems to lose the tone of its muscular coat, and yields to the 
enormous distension, till finally, through some irritant influence the muscu- 
lar coat is stimulated to contract, causing vomiting and throwing off of 
large quantities of accumulated material, to the speedy relief of the 
patient. I have frequently met with cases in which patients only mode- 
rately troubled with habitual indigestion and constipation, would be sub- 
ject occasionally, through some cause difficult to trace, to failure in the di- 
gestion of their supper. Taking their evening meal at the usual time, 
they would pass the evening, especially the early part of it, without any 
more than moderate sensations of heaviness, and oppression near the lower 
end of the sternum, and retire, perhaps, exhibiting nothing serious. Fall- 
ing asleep, in less than an hour, they wake up with extreme gastric dis- 
tress, and with all the severity and character of the symptoms I have just 
previously described. Continuing in this condition, unless relieved by 
some remedies, for two or three hours, it ends in belching large quantities 
of gas, and sometimes vomiting the greater part of their evening meal in 
a sour and undigested condition. Immediately after this the pain begins 



INTESTINAL PARASITES. 843 

to abate, and very soon they are so far relieved as to fall asleep. Getting 
two or three hours of sleep, they rise in the morning feeling weary, more 
or less depressed mentally, but usually able to take a light breakfast. 
Going out in the open air soon after, they recover their usual spirits and 
buoyancy and frequently go weeks and months before another attack oc- 
curs. Some of these attacks of gastrodynia are almost as distressing as 
those of genuine angina pectoris and are of the same general character, 
only the pain is epigastric and generally associated with more or less 
gaseous eructations, while in angina pectoris the pain is more in the chest, 
radiating to the left arm and shoulder, and accompanied by irregularity 
of the heart's action. In these cases of gastrodynia, where it is evident 
that the patient's last meal is not digested and removed from the stomach, 
but is still lying there in a fermenting condition, having much to do in 
causing the suffering, the most speedy means of relief is the administra- 
tion of a mild emetic, of which, perhaps, ipecacuanha is preferable to 
any other. Enough should be given to make sure of a speedy and free 
vomiting, aide! by a liberal drink of warm water. By filling the stomach 
with warm water directly after a moderately full dose of ipecac, vomiting 
is quickly provoked. If there is a little slowness in the subsidence of 
the pain after the stomach has been freely evacuated, any miid anodyne 
and antiseptic, more particula;ly a teaspoonful of the carbolic acid mix- 
ture, will usually be sufficient to arrest the further progress of pain and 
speedily induce a state of sleep. Of course after this the main object 
must be to correct the fauity condition of the digestive organs which 
have rendered such attacks possible. 



LECTURE LXXXIX. 



Intestinal Parasites— Their Varieties, Symptoms and Treatment. 

GENTLEMEN: The study of helminthoiogy is one of sufficient interest 
to justify you in giving it much careful attention during the earlier 
years of practice, when time may be afforded for further special studies, 
beyond what the more crowded hours of the lecture room would 
justify. Those parasites which have been found in the human body 
have been usually classed as entozoa. Thirty or more different varieties 
have been recognized as occasionally found in some part of the human 
system. The principal ones may be divided into three classes: the cestoid 
or ribbon-like worms, frematoid or fluted worms and the nematoid or 
round worms. To the first class, or cestoid worms, belong the different 
varieties of taenia; as the taenia solium, taenia lata, taenia echinococcus, 
several varieties of cysticercus, and the bothriocephalus latus. The 
frematoid worms are usually flattened and somewhat fluted, corrugated 
and soft, and are found mostly in the interior and parenchyma of organs. 
The class of nematoid worms embrace the more common varieties as the 
ascarides, which chiefly inhabit the rectum; the ascaris-lumbricoides or 
common round worms, which more generally occupy the small intestines 
and sometimes the stomach; the trichocephalus, oxyuris vermicularis and 
trichina spiralis. It is not my purpose at the present time to occupy 
your attention with any of the more rare varieties of worms or those which 



844 INTESTINAL WOEMS. 

are found in the interior of solid organs and cysts. Echinococci in cysts 
of the liver and other parts, cysticerci found in the eye and some other 
places are so rare as to constitute curiosities in medicine rather than items 
of ordinary interest to the practitioner. But I shall occupy your time at 
the present hour, simply in a brief consideration of the symptoms and the 
best mode of treatment applicable to the removal of the three most com- 
mon varieties of intestinal worms, namely, ascarides or pin worms, as they 
are sometimes called, the different varieties of lumbricoides and the taenia 
or tape worm. The two fist varieties are found more frequently in the 
intestinal canal of children and young persons than in adults. While the 
different varieties of tape worm are quite as often, perhaps more frequently, 
found in adults than in children. The ascarides are a small worm, flattened, 
a little tapering toward the head, and usually occupying the rectum 
and lower part of the colon. They multiply with great rapidity, are often 
discharged with each evacuation from the bowels in considerable numbers, 
usually sufficiently alive to make their crawling movements with consider- 
able facility; and when they are allowed to accumulate, they not infre- 
quently crawl out of the anus in the intervals between the intestinal evac- 
uations. The general symptoms to which they give rise are some tickling 
sensations or itching in the rectum and anus, together with some degree 
of increased nervousness or general excitability on the part of the patient. 
Their movements, not infrequently, apparently cause the child to start 
suddenly during sleep in the night, making him restless and sometimes 
starting up as in a fright. It is generally supposed that the existence of 
worms, especially of this variety, cause also more or less dryness and itch- 
ing in the nostrils, thereby inducing the child to rub his nose frequently. 
But rubbing the nose and dryness of the nostrils may arise from so many 
different causes quite as readily as from the influence of worms, that they 
are of little or no value, as aids in diagnosis. In fact the only certain 
diagnostic sign is the finding worms as they are discharged with the fasces 
from time to time, or as they make their exit after crawling from the lower 
opening of the bowels between the evacuations. When they are allowed 
to accumulate for a considerable time, they undoubtedly are capable of 
exciting sufficient irritation upon the nerves of the rectum to induce a 
reflex influence upon the nervous centers and temporarily establishing 
febrile reactions, by which children become subject every few days to 
temporary paroxysms of fever in which the face will appear flushed, the 
skin will become hot, breathing a little hurried, nostrils more or less dry, 
the nervous system disturbed, indicated by startings and excitability; and 
perhaps in three or four hours the paroxysm passes off and the patient 
will be up and apparently as well as ever. In other instances, however, 
the worms may exist for a longer period of time without inducing any 
active, febrile paroxyms, giving rise to nothing more than nervous rest- 
lessness at night, and more or less itching and annoyance in the rectum. 
As I have already remarked this variety of worm is found discharged in 
large numbers with the ordinary evacuations from the bowels, or they may 
be dislodged also freely at any time by taking almost any variety of physic 
that will produce two or three free evacuations. But very frequently, 
purging will entirely fail to remove all the worms or their larvae, and con- 
sequently they are reproduced in considerable numbers within one or 
two weeks, even if evacuating remedies have been used with as much 
freedom as is for the comfort of the patient. Generally the exhibition of 
vermifuges or special remedies, calculated to deaden the worms and cause 
them to pass off, produce less effect upon this variety than upon others 
occupying the upper or middle part of the bowels. Remedies calculated 



TEE ATM EXT. 845 

to destroy these parasites, given by the stomach, in passing through the 
alimentary canal do not reach the worms in sufficient strength to produce 
the desired effect. 

So little certainty is there of effectually removing ascarides or pin 
worms by the exhibition of vermifuge remedies by the mouth, that for 
many years I have almost ceased to use that class of remedies, and have 
very satisfactorily removed this variety of worms by means of enemas. 
The use of a solution of common salt in water in proportion of eight gram- 
mes (3i>) of the chloride of sodium or common salt to half a pint of water, 
and this quantity, or as much of it as the rectum will permit, shouldbe given 
as an enema, endeavoring to have the patient retain it for ten or fifteen 
minutes. By using enemas of salt water, the saline having a poisonous 
effect upon this variety of worm, you not only destroy those that are al- 
ready mature, but if the rectum is pretty well filled, it reaches almost cer- 
tainly the larvae also, and by destroying both, there is less liability for the 
worm to be reproduced and require treatment again in a few weeks or 
months. I have generally used the salt water enema twice a week for 
about two weeks in succession, and it is very seldom that this fails in en- 
tirely removing the further development of these parasites. If the bowels 
are inclined to be constipated it may be well, in addition to the use of 
enemas, to give the patient a mild laxative once a day, with which may 
be combined a few drops of oil of turpentine, which will be likely 
to reach and destroy any of the worms or their larvse, that may be too 
high up in the alimentary canal for the enema to reach. Besides salt water 
as an injection, there are many other things that may be used in the same 
manner that would prove effectual for the removal of this variety of worms 
An emulsion made by rubbing up a certain amount of oil of turpentine and 
castor oil, with mucilage and water sufficient to dilute the enema will 
generally prove effectual, although it is less convenient, and usually not 
more efficient than solutions of common salt. An infusion of spigelia 
marylandica, mixed with a little senna, may also be used as an efficient in- 
jection or enema for the destruction of the worms inhabiting the rectum. 
The ascaris lumbricoides, or long round worm, frequently found occupy- 
ing some portion of the small intestine and occasionally the stomach, may 
exist for an indefinite period of time, and produce so little inconvenience 
to the patient or positive symptoms by which their existence could be 
suspected that the patients have no thought of anything disturbing their 
health. And not infrequently, the first thing which causes them to think 
of worms is the discovery of a specimen mixed or incorporated with the 
faeces that have been discharged as ordinary evacuations. So true is it 
that in many cases there appear no symptoms of their existence, and 
many persons are found to pass large specimens every now and then, who 
are not conscious of suffering any symptoms of ill health. But where they 
multiply in the intestines until a considerable number have accumulated, 
they usually produce an obscure train of symptoms, such as chilliness, oc- 
casional paroxysms of fever, not having any regularity, but skipping a day 
or two, and then again returning, without any regularity as to the interval 
between their occurrence. Sometimes patients afflicted with these worms 
have a variable appetite, eating at some meals unusually voracious, and 
at others taking out little or none. The presence of the worms or their 
effect upon the nerves connected with the small intestines, has been sup- 
posed capable of exciting reflex disturbance of the nervous centers suffi- 
cient to provoke paroxysms of general convulsions. During a somewhat 
protracted period of practice I have seen but very few instances in which 
there was any satisfactory evidence that intestinal worms were the cause 



846 PARASITES. 

of convulsions or more than very evanescent paroxysms of fever. The 
bowels are usually regular though sometimes they are inclined 10 constipa- 
tion, at other times to diarrhoea. The same rule applies to the symptoms, 
which are so often regarded as indicating worms, namely, rubbing or itch- 
ing of the nose. And the only means for positive diagnosis or determining 
whether this variety of worms exists, is in finding some of them in the 
evacuations. Occasionally one comes up in the oesophagus from the 
stomach, and is cleared out of the throat. I met a patient only yesterday, 
who had discharged a worm, apparently from its rising in his oesophagus, 
creating the sensation as if encouraging the act of vomiting, and a little 
effort threw out a worm of the round lumbricoid variety some four inches 
long. 

Treatment. — A considerable number of remedies have been recommend- 
ed from time to time for the removal of this variety of worm, any one 
of which will succeed in most instances, if it be given properly, arid fol- 
lowed at the proper time by a moderately brisk cathartic. A very old 
and favorite remedy, in years gone by, was the spigelia marylandica. 
When a child or young subject was found to be affected by worms of the 
lumbricoid variety, the common practice was to take eight or ten grammes 
(311) of the spigelia root, with an equal quantity of the senna leaves, 
to which was added sufficient water, boiling hot, to make 200, c. c. 
(fvi) of the infusion. This can be given in divided doses, suited tc the 
age of the patient, once in three or four hours until it produces three or 
four free evacuations. The spigelia, or pink root, is supposed to deaden 
the worms, while the senna, acting as a cathartic, causes their discharge. 
Equally effectual is it to give eight or ten minims of the oil of turpentine 
on a little sugar, or rubbed up with gum arabic and sugar in the form of 
an emulsion, three times a day for two or three days, and follow it by a 
moderately brisk cathartic. Another remedy which is usually efficient, is 
santonine; which from the smallness of the dose is more convenient of 
administration to children than either turpentine or the spigelia, though 
the latter may be obtained in concentrated form by giving the fluid ex- 
tract. Santonine for children from three to five years of age may be given 
in doses of from one to three grains in the form of a powder, morning, 
noon and evening, and the next morning followed by a cathartic, or a 
dose of the santonine may be given morning and noon, and the third to be 
given at night, may be mixed with a sufficient quantity of rhubarb, 
powdered senna, or of calomel, to produce a free movement of the bowels. 
But the existence of worms in the bowels is much less frequent than is 
usually supposed by the greater portion of the community. A large 
portion of the cases of disease that are supposed to originate from worms 
are cases of simple irritation of the mucous membrane of the alimentary 
canal, or some morbidly excitable condition of the nervous system when 
there are no worms of any variety existing in the alimentary canal or any 
of the adjacent viscera. The taenia, or tape worm, occurs more frequent- 
ly in adults than in children, but may be found at any period of life. It 
usually occupies the small intestines, and is far more difficult of dis- 
lodgment, or removal, than either of the varieties that we have just been 
considering. Like the two other varieties of worm, their existence is not 
productive of any absolutely characteristic or diagnostic symptoms, ex- 
cept the discovery of a portion of the worm in the discharges from the 
bowels. Indeed, a large majority of all the patients I have met, when 
annoyed with the existence of tape worm, have not been conscious of any 
particular ill health or even of symptoms of indigestion, till they accident- 
ally discovered sections of the worm in the evacuations. Most patients 



TAPE WORMS. 847 

after they have learned that the worm exists in the alimentary canal, by 
witnessing the discharge of sections of flat and truncated pieces day 
alter day, become annoyed with what they will describe as various un- 
pleasant sensations derived from the presence of the worm. They will 
not infrequently speak of a crawling, creeping, turning, twisting motion 
of the bowels; sometimes having a voracious appetite, and at other times 
none at all. They generally become very nervous, and not infrequently 
complain of choking sensations in the neck like parties affected with 
hysteria. Most of these sensations, however, are evidently the result of 
mental education, and watching for some sensation in the abdomen, aided 
by the imagination of the patient, as to what would be the effects of the 
presence of the worm, more than what was actually felt, or that they had 
any knowledge of, prior to having become satisfied that the worms existed. 
And yet, it is probably true that the presence of this variety of worm, 
especially when it has attained considerable size, causes many obscure and 
annoying feelings in the abdomen, which are sometimes reflected to the 
central portion of the nervous system, giving rise to temporary periods of 
excitement or feverishness, disturbance of sleep at night, associated with 
a disposition to perform the act of deglutition, or a sense of choking 
in the neck. These worms sometimes attain great length, being broad, 
flat and jointed, tapering almost to a point, with a little bulb at the end 
constituting the head. This head in most cases is armed with antennae, or 
little hooks, projecting from either side of the enlargement. The worm 
grows broader and keeps a distinctly flattened form as it extends in length 
until when it has attained a pretty full size, each section is from three to 
six lines wide and about the same in length. These pieces, although 
detached sections of the worm, are most of them, when passed, possessed 
of sufficient vitality to make very distinct and sometimes regular move- 
ments, such as contracting and extending in width, and crawling, or more 
or less of a progressive motion. But the difficulty for the physician is not 
usually in the diagnosis. The worm, when joints of it are presented, is 
easily recognized and its general habits and disposition for reproduction 
understood. But the chief point of interest, both for the physician and 
patient, is the best mode of treatment, or the one most certain to effect its 
entire removal. For this purpose quite a long list of remedies have been 
used, and from time to time, each in its turn has been recommended as 
efficient. The principal difficulty in removing this variety oi worm, is 
in getting any medicine to reach it in sufficient strength to act as a poison 
or to so deaden the worm as to loosen its hold, or the grasp of its hooks, 
upon the folds of the intestines. Occupying a particular portion of the 
alimentary canal, and involved more or less in the fecal contents of the 
intestines, whatever is administered by the mouth, or by the rectum, be- 
comes so diluted by its intermixture with fecal matters or removed by 
absorption before it has reached the worm, that it is not of sufficient 
strength to produce the desired effect upon the parasite. Consequently, 
if we would obtain the greatest degree of certainty in the removal of the 
worm by any particular plan of treatment, we will be very much more 
likely to succeed if the bowels are first emptied by the administration of 
sufficient laxatives, and che patient during the time of treatment abstains 
either from all nourishment, or from all solid food, taking at each meal 
time, only just such limited amounts of liquid nourishment as will pre- 
vent too great a degree of exhaustion from the abstinence. After empty- 
ing the alimentary canal, and taking a very small amount of liquid 
nourishment, the worm becomes exposed, or as free from envelopment by 
the contents of the bowels as is possible. Having placed the patient in this 



848 TAPE WOEMS. 

condition, whatever remedies are chosen to exert a toxemic or poisonous 
influence upon the worm should now be administered in sufficient doses, 
and repeated as often as the nature of the medicine will permit with 
safety, for eighteen or twenty-four hours, during which its full effect on 
the worms may be developed. This should be followed immediately by one 
pint of previously prepared infusion or mucilage of pumpkin seeds, drank 
at once. This will usually cause, in five or six hours, one or more free 
intestinal evacuations, carrying with them the entire worm. When evac- 
uations do not follow in the time mentioned, a full dose of physic should be 
given to hasten the desired result. During the time occupied by the 
active treatment, the patient should take sparingly of liquid nourishment 
only. 

This plan of treatment, when judiciously and faithfully executed, 
has succeeded in expelling the entire worm in three cases out of 
four. When it has failed, after allowing the patients a few days to re- 
cover from the debilitating effects of two or three days of fasting and evac- 
uents, I repeat the same plan of treatment, and almost always with suc- 
cess. The variety of the worm having hook-shaped antennae are the most 
difficult to expel. The only evidence of complete success is the finding 
of the head of the worm, which you distinguish from the other parts by its 
being a slight bulb or enlargement at the end of a long neck that had ta- 
pered almost to a point. Among these specimens, which I show you from 
the college museum, are some in which the head is readily distinguished. 
Concerning the best vermifuge or toxic agents to affect the different 
varieties of tape worm there is much difference of opinion expressed by 
writers and practitioners. I have succeeded best with the fluid extract of 
the pomegranate bark and the etherial extract of felix mas or male fern. 
J give the first in doses of four cubic centimeters (fi. 3i) every three or 
four hours until five or six doses have been taken; and the second in half 
that quantity just as often, following them with the mucilage or infusion 
of pumpkin seeds. These doses are for adults, and each dose should be 
given diluted with a little sweetened water. In many cases I have given 
the pomegranate and male fern together, and occasionally have had the 
worm expelled before it was time to give the pumpkin seed tea. Besides 
the remedies I have mentioned you will find recommended in your books 
the flowers of the Brayera anthelmintica called kousso; the rottlera tincto- 
ria, called kameela; carbolic and salicylic acids, and large doses of oil of tur- 
pentine or petroleum. Indeed, there are a great variety of remedies which 
have occasionally proved successful in expelling tape worms. The first 
tape worm I met with after entering upon the practice of medicine, was 
expelled while the patient, a young woman, was taking purgative doses 
of the powdered colchicum root. I must caution you, however, against 
resorting to excessive doses of drastic cathartics or of such oils as are 
liable to induce inflammation of the mucous membranes, either of the in- 
testines or urinary organs. They are not only unnecessary, but liable to 
do much injury. Several cases have come under my care, in which oil of 
turpentine had been taken in from four to sixteen cubic centimeters (fl. 
3i to 3iv) at a dose, resulting in tenesmas, excessive stranguary and 
bloody urine, from which the patients did not recover fully for several 
months, and yet without having expelled the worm. 

With a proper attention to the preparation of the patient and the regu- 
lation of the diet, milder measures will be found not only safer, but uni- 
formly successful in relieving the patient of his dreaded parasite. 

As all this class of parasites are supposed to gain access to the aliment- 
ary canal in the form of larvae or germs contained in pork and other varie- 



TRICHINA SPIRALIS. 849 

ties of mecit that has been taken for food, it suggests a prophylactic at once 
effectual, and within the reach of every family. It is simply to avoid all 
use of raw or inadequately cooked meats. And this leads me to say a few 
words about the trichina spiralis. 

This parasite belongs to the group called nematoid, and first began to 
attract attention in the decade between 18"20 and 1830. It is found most 
abundantly in the muscular structures of the hog, and, in a less degree 
however, in the flesh of almost all domestic animals. It gains access to 
the human system in the meat that is eaten, and is capable of multiply- 
ing rapidly and permeating from the intestines into nearly all the mus- 
cular structures of the body. When it exists only in small numbers, 
either in man or animals, it appears to exert very little influence upon 
the health. But when meat is eaten containing large numbers, it is apt 
to be followed first by all the symptoms of gastro-intestinal inflammation, 
such as vomiting, diarrhoea, severe griping pains, and rapid prostration. 
After a few days these symptoms abate, but are soon followed by severe 
pains and hypsrsesthesia in one set of muscles after another until the pa- 
tient is tortured with irregular pains and great soreness in almost all parts 
of the body and extremities, under which he may reach a fatal stage of 
exhaustion in from one to four weeks, or may slowly recover. A large 
proportion of the more severe attacks have terminated fatally in opposi- 
tion to any form of treatment thus far devised. 

Post mortem examinations have shown that the trichinae exist in large 
numbers in various stages of development in most of the voluntary 
muscles of the body and extremities; and in cases which have terminated 
in death early, they are still found in the intestines. 

Treatment. — After the trichinous disease has become fairly developed, 
no remedies have been found capable of exerting a satisfactorily control- 
ling influence over its progress. 

But few cases have come directly under my care, and consequently my 
opportunities for clinical observation in the treatment of the disease have 
been limited. In the first stage while the prominent symptoms are those 
of gastro-intestinal irritation, the following mixture has afforded more re- 
lief than anything else prescribed: 

^ Acidi Carbolici 0.500 grams gr. viii 

Glycerinse 30.000 c. c. §i 

Tincturse Opii Camphoratas 60.000 c. c. |ii 

Aquae J0.000 c. c. |i 

Mix. To adults four cubic centimeters (fl. 3i) may be given every two 
or three hours until the vomiting and diarrhoea cease. After the gastro- 
intestinal symptoms abate, if the symptoms of pain and soreness in the 
muscles show that the parasites are developing in the muscular structures, 
I think it better to substitute from three to five decigrams (gr. v to viii) of 
salicylic acid in the place of the carbolic, leaving the other ingredients the 
same. If the patient survives the active stage and convalescence ap- 
proaches, little else than rest and easily digestible food is required for 
completing the recovery. 

Prophylaxis. — The only reliable mode of absolutely preventing the 
occasional occurrence of trichinosis is for all persons to avoid eating meat 
of every kind which has not been cooked or heated to 150° F., which 
renders it perfectly safe. 
54 



850 DIABETES 



LECTUEE XC 



Diabetes- Varieties, Clinical History, Prognosis and Treatment. 

GENTLEMEN: Among the more important disorders connected with 
the functions of excretion, which have not been already passed in 
review, are the varieties of diabetes. This word signifies increased flow 
of urine, and clinically we meet with two varieties of the disease, one 
called diabetes insipidus, and the other diabetes mellitus. The prominent 
feature of the former is excessive flow of urine without material alteration 
of its constituents, while the latter, diabetes mellitus, is sometimes called 
glucosuria, from the fact that it not only presents a very great increased 
flow of urine in a given length of time, but the urine contains an abnormal 
amount of sugar. Both these forms of diabetes are met with more fre- 
quently during the early period of adult life than either in childhood or old 
age, although cases have been known to occur at all periods of life, even 
in infancy. Both varieties are said to occur much more frequently in 
males than in females. 

Diabetes Insipidus. — The causes of this variety are very obscure, but 
facts seem to show that in a large proportion of cases exposure to cold, 
damp air, particularly living in damp rooms, with but little access of sun- 
light, directly favors the development of the disease. Drinking cold liq- 
uids when the body is warm or excited from severe exercise has been al- 
leged as a cause in some cases, injuries affecting the brain or spinal cord, 
such as blows upon the head, shocks, and penetrating wounds, particularly 
when affecting the base of the brain or portions of the medulla oblongata, 
have been followed by this form of disease. While cases are on record 
of diabetes insipidus in which some one or more of the causes enumerated 
would appear to have exerted an important influence in their development, 
there are others in which it is difficult to trace any cause adequate for the 
production of the disease. It is probable that hereditary influence exists 
in some instances. 

Symptoms. — Simple or insipid diabetes not infrequently commences 
abruptly, but in some instances its development appears to be stow and 
insidious. But whether abrupt or insidious, as soon as it has made suf- 
ficient progress to present a noticeable increase in the amount of urine 
passed in the twenty-four hours above normal, there is observed greater 
paleness of features, accompanied generally by an excited expression of 
countenance, some degree of mental despondency, frequently obscure, dull 
pains in the loins, occasionally aching in the lower extremities, although 
both these latter symptoms are not infrequently absent. The patients 
also tire easily, indeed, feel a sense of weariness a large part of the time, 
even when not undergoing muscular exercise. But the most prominent 
symptoms are the excessive quantity of urine passed, and the marked 
thirst or desire for drink. The latter, or desire for drink, increases at an 
almost uniform ratio with the increase in the flow of urine. After the 
disease has progressed for a few weeks, there is noticeable diminution of 
•flesh, or emaciation, the skin becomes dry and rough, the mouth habitually 
dry, sometimes, on -rising, giddiness or dizziness in the head, startings and 
restlessness in sleep at night, and, if the disease continues to progress, the 
patient becomes more and more emaciated, the skin dryer and more 
husky, the strength wastes till in some instances the exhaustion reaches a 



TREATMENT. 851 

fatal degree of progress. More frequently complications spring up in the 
latter stages of the disease, either in the form of diarrhoea, involving ex- 
cessive discharges which speedily end in collapse and death, or in the 
development of local inflammation in the serous membranes, such as the 
pleura or pericardium, followed by copious effusion, and sometimes death. 
The disease is very persistent, nor is it amenable with certainty to any 
known mode of treatment. 

Anatomical Changes. — It can not be said that post mortem examinations 
have revealed any structural changes which may be regarded as charac- 
teristic or peculiar to this form of disease. In some the kidneys have been 
found somewhat atrophied, in others they are enlarged and congested, in 
still other cases there has been found more or less fatty degeneration; 
and yet there are rare instances in which no morbid changes have been 
found, and instead of structural lesions in the kidneys, a few congested 
and altered appearances have been found in the ganglia of the sympathetic 
nerve. In a few cases morbid appearances have been seen in the liver; 
but as I have already remarked most of these changes have resulted from 
the influence of complications, rather than as a legitimate part of the di- 
abetic affection. The essential pathology is certainly not well known. 
There are reasons to believe that the most constant pathological condition 
connected with the disease is dilatation of the capillary vessels of the kid- 
neys, under some faulty influence of the vaso-motor nerves. 

Prognosis. — The prognosis in this variety of diabetes must always be 
given with caution; for while a considerable proportion of those cases that 
are brought under treatment early, and the patients are in the middle 
period of life, recover, yet, where the early stage has been neglected, and 
in some instances even where treatment has been adopted from the begin- 
ning of the disease, the morbid action continues until the patient becomes 
fatally exhausted. 

Treatment. — One of the important items in the management of all cases 
of diabetes insipidus, consists in a close examination of the history of the 
patient with a view of ascertaining as far as practicable the causes which may 
have had an influence in developing the disease, and to prevent their 
further action. The hygienic management is also of great importance. 
The patient should be required to wear warm flannel underclothes, oc- 
cupy well lighted and warm rooms, with good ventilation and ample sup- 
ply of pure air. He should take just so much exercise in the open air 
every day as his strength will allow; limit his drinks to a moderate quan- 
tity of milk whey, or buttermilk, and the class of mineral waters represented 
by those of Waukesha in Wisconsin, and which are found of a similar 
character in many parts of this country. It is not desirable or advan- 
tageous to punish the patient by actual deprivation of drinks, but the 
quantity should be limited as much as the patient can bear without too 
much discomfort. Many of the cases are accompanied by a rather vora- 
cious appetite. If so, some degree of restriction should be placed, suffi- 
cient at least to limit the quantity to the capacity of the stomach, to digest 
fully; otherwise the patient's condition will be aggravated by indigestion 
and the fermentation of the excessive quantities of food in the stomach. 
Such gastric disorders disturb still more the nervous centers, and radiate 
an increasingly disturbing influence upon the vaso-motor nerves and there- 
by increase the diabetic difficulty. A great variety of remedies have been 
tried in this form of diabetes, but very few of them have been found ca- 
pable of producing permanent benefit. Nitrate of potassium, iodide of 
potassium, and the carbonated alkalies have been given sometimes with 
apparent advantage, but usually without exerting any material influence. 



852 DIABETES MELLITUS. 

Almost every variety of astringent, vegetable and otherwise, such as tan- 
nin, gallic acid, alum and preparations of iron, have been given with a view 
of exerting a tonic or astringent influence upon the capillary vessels of the 
kidneys, and thereby lessen the flow of urine. So far as my own observa- 
tions go I have seen but little benefit from the use of any of these reme- 
dies. Within the last few years some cases of a very well-marked char- 
acter have been under my care, in which the patients derived decided ad- 
vantage from the use of a reliable preparation of ergot, either in the form 
of ergotin or the fluid extract. Two of the cases to which I allude were 
placed upon the use of ergot and glycerine combined, two parts of the 
glycerine and one of the fluid extract of ergot, of which the patient, who 
had arrived at adult life, was given, at first, two cubic centimeters (fl. 3ss), 
but which was gradually increased to four (fl. 3i) at a dose, four times in 
the twenty-four hours. Each dose of the medicine was given largely 
diluted with water. Two or three times during the treatment of these 
cases sufficient doses of pilocarpine were given to produce the character- 
istic flow of saliva and diaphoresis. In one of them moderate doses of 
codeine were given every night, partly for procuring rest, and partly for its 
effect in lessening the urinary secretion. Under the same treatment, con- 
tinued in the one case three months, and in the other two, recovery took 
place, each for a considerable length of time continuing without a relapse. 
After several months both patients passed beyond my observation, conse- 
quently I have not learned whether subsequent relapses took place or not. 
In two other cases similar measures produced amelioration of the symptoms, 
and rendered the patients very much more comfortable for a long period of 
time, and yet, ultimately, failed to control the disease. Where the skin is 
very dry, as is true in most of the cases, a warm bath twice a week followed 
by light, rapid frictions of flannel over the whole surface, is well calculated 
to aid in ameliorating the condition of the patient. In some cases, also, 
the moderate influence daily of electricity or galvanism, applied with the 
positive pole upon the back of the neck or below the occiput, and the 
negative alternately over the loins and over the epigastrium, has been found 
to aid in diminishing the prominent symptoms of the disease. 

Diabetes Mellitus. — Perhaps more frequent than the insipid variety, and 
decidedly of greater importance because more persistently tending to the 
destruction of the patient, is that form of diabetes in which the increased 
flow of urine is accompanied by constant, or nearly constant, excess of 
glycogen, or sugar. There are two classes of patients subject to attacks 
of this variety of diabetes: The one class are naturally of spare form and 
rather nervous temperament; the other, decidedly obese from an excess of 
fatty nutrition. So far as my own observation has gone, nearly all the 
cases of the latter variety have been females. I have seen but two in- 
stances in which diabetes mellitus existed in males presenting a decided 
predominance of fatty nutrition or obesity; while three or four times that 
number of females are still fresh in my recollection. But whatever may be 
the temperament of the patient, this form of diabetes almost always com- 
mences slowly and very obscurely. The first symptoms which usually at- 
tract the attention of the patient, or his friends, are an unusual feeling of 
weariness and consequent indisposition to exertion, together with an in- 
ordinate desire for drink, and in some cases, also, an unusual appetite for 
food. And though taking with a relish, perhaps an excess of both food and 
drinks, yet he finds his strength from day to day diminishing, with in- 
creased weariness, aching in the limbs, and sometimes in the loins. 
In a few weeks after the symptoms are first observable, there will usually 
be more or less derangement of digestion, the patient by his appetite 



SYMPTOMS. 853 

being induced to take more food than there is gastric juice to impregnate 
or prevent from fermenting, the period of digestiou becomes disturbed by the 
formation of gaseous eructations, in some cases tasteless, in others strongly 
acid. The bowels are apt also at this period to be more or less constipated. 
These symptoms almost always induce patients to think that they are 
either bilious or dyspeptic, and consequently they resort to remedies of 
their own, choosing usually some form of physic, but which does not af- 
ford them any of the relief they had anticipated. Usually in from one to 
three months from the first beginning of symptoms they will have reached 
a degree of weakness, thirst, unusual appetite, loss of flesh, dryness and 
huskiness of the skin, dryness of the mouth, which impresses upon them 
the conviction that it is time to seek medical aid. It is in this condition 
that a large majority will first present themselves to their physician. When 
they come to you under such circumstances, you will find them with a pulse 
soft, weak, easily compressed, but little or not at all increased in frequen- 
cy ; extremities rather cold and having a congested look, from the slowness 
of the circulation in the cutaneous capillaries; the voice rather weak, lips 
looking dry, and countenance often pinched, from more or less shrinking 
or emaciation. They will complain of weakness, despondency, some de- 
gree of indigestion, having constipation the greater part of the time, but 
occasionally alternated with short turns of diarrhoea or looseness of the 
bowels. Many also present a slight dry cough and a very dry corrugated 
and husky feeling of the skin. 

Such symptoms should always cause you to suspect the existence of 
diabetes. In order to render the examination of the patient complete, it 
is not only necessary to ascertain from him that he is making a larger 
quantity of urine than natural every day, as well as drinking more largely, 
but a specimen of the urine should be obtained for direct analytical ex- 
amination. If a specimen of urine is subjected to proper tests, it will be 
found of high specific gravity, usually varying from 1020 to 1040, a lit- 
tle paler in color than natural, having a very slightly turbid appearance, 
although in many cases it remains as clear as spring water. The most 
common test, or that which is sufficient for clinical purposes, is known 
as Trommer's test, or the modification of it proposed by Fehling. This 
test consists essentially in first placing in a test tube equal quantities 
of a solution of sulphate of copper and of caustic potassae, then adding a 
few drops of the suspected urine and heating it over a spirit lamp until 
it boils. The reaction between the liquor potassae and the copper are 
such if sugar is present as to cause a precipitate of the insoluble sub- 
oxide of copper of an orange or brick red color. Fehiing's test consists 
in a ready formed solution containing a proper proportion of the copper 
and potassae; and by placing a small quantity of this in a test tube, and 
adding directly to it a few drops of the suspected urine, and then bring- 
ing it to a boiling heat over the spirit lamp the copper is reduced and the 
characteristic orange red precipitate is formed in the solution. This is a 
very convenient test because it can be quickly applied, but the liquor is 
liable to change after long standing, and consequently should be pre- 
pared fresh at short intervals of time. The amount of sugar in the urine 
will be indicated by the quantity of precipitate formed. To judge of 
the quantity of the sugir excreted it is necessary to take into account 
both the ratio of precipitate that is formed in a given quantity of urine 
in the test glass, and the actual absolute quantity of urine passed in the 
twenty-four hours. And as many patients with diabetes mellitus, after 
the disease is well established, pass from one to three or four gallons of 
urine in the twenty-four hours, it can be readily seen by the indications 



854 DIABETES MELLITUS. 

of sugar in the test tube, that the quantity passed in the amount of wat^r 
named would be sufficient to require the appropriation of nearly all the 
food the patient could take instead of allowing any to remain for the 
proper nutrition of the tissues of the body. It is in consequence of this 
drain that most diabetic patients rapidly emaciate until their tissues are 
as attenuated as in the advanced stage of the slow wasting form of tuber- 
cular phthisis. When the extreme stage of exhaustion has been reached 
there are some instances' in which the feet and ankles become swollen or 
oedematous, but more frequently they become blue, cold, shrunken and 
sometimes are attacked with gangrene. More generally, however, before 
such results are reached the frequent turns of diarrhoea, and the imper- 
fect nutrition of the mucous membrane of the alimentary canal lead to 
collapse and death from pure inanition. But a large proportion of the 
cases of diabetes mellitus are also complicated with tuberculosis, and as 
they reach the extreme degree of exhaustion, the tubercular deposit in 
the lungs begins to develop active characteristic changes, and cause ex- 
pectoration and all the phenomena of consumption, thereby hastening the 
final termination of the case. 

The clinical history I have now given you applies more. especially to 
that class of diabetic patients who are not obese or subject to excessive 
fatty nutrition. In this latter class of cases there are usually certain im- 
portant modifications in the progress of the disease. There is the same 
thirst, the same excessive flow of urine usually with quite as large a pro- 
portion of saccharine matter in the urine when voided, but these cases 
differ chiefly in the fact that their tissues emaciate but slowly, retaining a 
decided fullness from fatty deposit and a look of obesity to a very late 
stage of the disease. As they arrive at an advanced period in its prog- 
ress there is almost always the occurrence of a most troublesome and 
sometimes reniakable development of boils, abscesses and carbuncles that 
may make their appearance in any part of the cutaneous surface and some- 
times occupy almost the entire surface of the body. Two or three years 
since, one of the most striking cases of this class came under my observa- 
tion in the west division of the city. It was a woman about forty-five 
years of age, who had during the earlier part of life enjoyed apparently good 
health and was the mother of a large family of children. She had acquired 
a strongly marked fatty accumulation, sufficient to give her a weight 
of nearly two hundred pounds. She was attacked with diabetes mellitus, 
and as far as I could learn it had come on in the usual way, insidiously, 
and had been continuing at least six or seven months at the time I was 
called in consultation in the case. She presented the most striking: pict- 
ure of a human being covered with boils, abscesses and carbuncles (the 
latter varying in size from half an inch to three inches in diameter), that 
I have ever seen since I have been engaged in the practice of medicine. 
These larger carbuncles were distributed over the whole posterior part of 
the body, from the neck down to the gluteal regions, while the anterior 
part of the trunk and more or less of the extremities were covered with 
hard, prominent, slowiy suppurating boils, with half a dozen or more cellular 
abscesses in different parts of the body. This poor woman lingered two 
months more in great misery from these sores when she was relieved by ar- 
riving at the fatal stage of exhaustion. Throughout the whole course of the 
disease the urine was strongly impregnated with saccharine matter, and the 
quantity voided was usually from three to six quarts in the twenty-four 
hours. I have seen no cases of this class recover. Two that I have had 
under treatment, temporarily convalesced, and remained apparently nearly 
free from any excess in the quantity of urine or appearance of saccharine 



PATHOLOGY. S55 

matter for several weeks at a time, when both would return, but under 
treatment would again be checked, and one of them, after its being kept 
in abeyance a considerable time, finally took on persistent or contin- 
uous symptoms, and terminated fatally; the other is still under treatment 
and has presented well-marked diabetic quantities of urine with sugar in 
it, accompanied by the same degree of thirst and moderate dryness of the 
skin for three or four weeks at a time and then disappearing under a 
certain amount of treatment, and remaining absent from two to four 
months at a time. Although this patient has lost from her previ- 
ously full, fatty habit, at least thirty or forty pounds in weight, she 
is still by no means emaciated, but would give to any observer the idea 
of a moderate degree of obesity. What will be the ultimate result re- 
mains to be seen. 

Pathological Changes. — The same remark may be made in regard 
to the anatomical changes found after death from diabetes mellitus as 
was made in reference to that of diabetes insipidus. In more than half 
of all the cases the patients are found to have more or less of tubercular 
deposit, sometimes in an entirely crude, primary condition, disseminated 
through the various structures, particularly in the lungs, but in some cases 
in the liver, spleen and kidneys, and at other times more advanced. Yet in 
many other cases no traces of tuberculosis can be found after death. Con- 
sequently it must be admitted that although there is some evident affinity 
or close relationship between diabetes mellitus and tuberculosis, they are 
not necessarily associated, or the one dependent upon the other, but that 
they frequently exist as coincident affections. The kidneys are found on 
post mortem examination in many instances moderately enlarged, softened 
or flabby in texture, in some instances paler than natural, in others hav- 
ing the appearance of congestion or hyperaemia. But there are no con- 
stant anatomical changes observable in these nor any other organs in the 
body. The liver in some cases presents a congested and enlarged condi- 
tion; in other instances, if there is any change, it is contracted and appar- 
ently less vascular than natural. Examination of the ganglia of the sym- 
pathetic and vaso-motor systems of nerves has revealed, in some instances, 
a congested or apparently inflammatory condition of the ganglia, especial- 
ly those along the trunks of that part of the nerves contained in the thorax 
and abdomen. Quite as often, perhaps, some obscure indications of disease 
have been observed in the medulla and base of the brain. It is a well- 
known fact that wounds inflicted, especially penetrating wounds, into the 
floor of the fourth ventricle, and in some portion of the base of the brain 
and medulla, sometimes produce all the phenomena of diabetes mellitus, 
increasing the flow of urine, and producing a copious amount of saccharine 
matter in it. Injuries of the brain from concussion and injuries to the 
spinal cord, have not infrequently resulted in the production of diabetes, 
or at least saccharine urine. It is quite evident from the absence of any 
uniform morbid condition of the kidneys, that we must look elsewhere 
than in these organs for the essential pathology of the disease. And since 
it has been well ascertained that the starchy and other carbonaceous con- 
stituents of the food are converted into glucose or sugar, in the further 
changes constituting assimilation or the passage from mere crude material 
as taken into the stomach to the constituents of blood, and still further, 
that these changes take place largely in the liver, many experiments have 
been performed on animals with a view of determining with some degree 
of certainty the function of the liver, so far as it relates to the conversion 
of the materials derived from the digestive organs into sugar. And al- 
though those performed by Bernard and by A. Flint, Jr., and a number of 



856 DIABETES MELLITUS. 

others, seem to show conclusively, or with a reasonable degree of cer- 
tainty, that sugar was a product of the changes which take place in the 
liver, still Pavy and others have claimed with almost an equal degree of 
plausibility that the production of the sugar found in the liver was the re- 
sult of the post mortem changes taking place speedily after the cessation 
of life, and not a natural product from the processes that had taken place 
in the healthy living organization from day to day. Without attempting, 
however, to decide this controversy, I think I am justified in assuming 
that a large proportion of the carbonaceous and especially the starchy 
constituents of food are naturally converted into sugar during the processes 
of digestion and assimilation. Whether this change is confined alto- 
gether to that part of the material that passes through the liver, and 
the transformation which takes place in the texture of that organ is part 
of its natural function, or whether the same general change is taking 
place more or less in all the glandular structures through which crude 
material passes from the stomach and duodenum on its way to reach the 
blood, is perhaps not clearly determined. But that such a change does 
take place there is, at least, reasonably satisfactory evidence, derived alike 
from experiments, clinical observations, and the chemical analysis of vari- 
ous secretions. It is highly probable that the first link in the chain of mor- 
bid action, or the essential pathology of diabetes, consists in the arrest of 
the assimilative process at the stage when sugar is developed; the natural, 
complete process consisting in a further change by which the sugar is 
converted into lactic acid and other constituents. But in the diabetic 
patient this further change does not result, and the product, as sugar, passes 
into the blood, filling that fluid with an excess of this material, the pres- 
ence of which stimulates the kidneys to increased activity, by which it is 
eliminated with a greatly increased quantity of urine. The enormous 
flow of urine, carrying with it the watery element of the blood, drains the 
tissues and creates the thirst. The gratification of this thirst for replet- 
ing the watery element of the blood, keeps up the material from that 
source, and perpetuates the ability of the patient to pass large quantities 
of urine. This view of the pathology of the disease is corroborated by the 
effects of regulating the diet. For, though the disease is not cured by 
such regulation of diet, yet whenever all those articles of food are excluded 
from use which are capable of being converted by the assimilative proc- 
esses into sugar, the quantity of urine and the amount of sugar excreted 
are both greatly reduced; so much so indeed as to show conclusively that 
there is a direct and persistent connection between the quantity of sugar 
evolved in the system and the amount of food the patient takes capable of 
undergoing such evolution. 



LECTURE XCI 



Diabetes Mellitus Continued— Diagnosis, Prognosis and Treatment— Enuresis. 

GENTLEMEN: Diagnosis. — Diabetes is not likely, after it is fairly 
established, to be confounded with any other disease except diabetes 
insipidus. From this it is distinguished by the chemical tests which de- 
termine the presence or absence of sugar in the urine, and as these tests 



TREATMENT. 857 

have already boon spoken of, and the characteristic symptoms fully pointed 
out while giving the clinical history of toe disease, thoy need not be re- 
peated under tins bead. 

Prognosis. — It must bo said that the prognosis in well formed diabetes 
mellitus is unfavorable; for though some cases have recovered under per- 
sistent hygienic and medical treatment, very much the larger number have 
persisted until a fatal termination has been reached. 

7V. atment. — As you might infer from the suggestions concerning the 
essential pathology of the disease, the important pirt of the treatment in 
all cases of diabetes consists in the hygienic regulations to which the pa- 
tient must be subjected. It is of great importance that the patients be 
supplied with pure air, rooms of comfortable temperature, clothing of such 
quality as will best secure the surface against sudden and severe atmos- 
pheric changes, of which fla inel next to the surface is perhaps the best; 
daily, moderate out-door exercise so long as the strength will permit, but 
without excess either of mental or physical exertion; a warm bath at least 
twice a week, followed by frictions of flannel to increase the activity of 
the circula'ion in the surface as much as possible, and to keep up the cuta- 
neous eliminations which are liable to become very limited and the skin 
veiy dry. The diet should be so regulated as to allow the least amount 
of carbonaceous, and especially starchy products of food that will be con- 
sistent with the continuance of digestion and assimilation. It is desirable 
to exclude totally the use of potatoes, turnips, beets, carrots and corn 
bread, and to some extent also the ordinary wheat and rye flour breads. 
Patients should be limited to the coarser brown breads, or still better to 
bread made of bran; to the free use of meat of any variety that they may 
choose, but especially good fresh lean meats, and for vegetables the celery, 
cabbage, onions, lettuce and spinach may be used with freedom. The 
patient may drink freely of milk whey, skimmed milk, and of buttermilk, 
but should use rather sparingly sweet milk containing the caseine nat- 
urally belonging to it. He can drink freely of certain mineral waters, 
of which the Bethesda spring water of Waukesha, Wisconsin, is a good 
representation. Eggs and butter, as well as some kinds of fruit, especially 
those containing but littie saccharine matter, may be allowed moderately. 
Tne moderate use of tea and coffee may also be allowed. Whenever the 
d sease is taken under care early, and the diet is rigidly regulated on the 
principles I have just indicated, eliminating or excluding all those articles 
that contain any considerable proportion of starch, gum or sugar, 
or other ingredients capable of being converted into sugar, but al- 
lowing a sufficient variety of the nitrogenous and other ingredients 
I. have enumerated to maintain healthy nutrition, such a course will 
greatly ameliorate the condition of the patient and retard the progress 
of the disease, without any medication whatever; particularly, if it be 
accompanied by thorough warm bathing and frictions upon the sur- 
face two or three times a week. But there are some medicines in which 
I have acquired considerable confidence as calculated to add much to the 
efficiency of the proper regulation of the diet and habits of the patient. 
After trying almost every remedy and combination of remedies that has 
been proposed in the last forty years I am sure that none of them can 
be relied upon as specifics for the cure of this disease. I have derived the 
greatest amount of benefit and in some instances have seen the disease 
entirely arrested, at least for a time, by giving careful attention to the reg- 
ulation of the bowels, obviating constipation, keeping the secretory func- 
tions, especially those concerned in excretion, as regular and healthful as 
possible, using such means as the condition of each individual patient may 



858 DIABETES MELLITUS. 

indicate. Whenever the tongue is coated, the patient feverish, and the 
bowels inclined to be costive, I have uniformly found advantage from 
giving three or four alterative doses of the mild chloride of mercury and 
following them by a laxative sufficient to procure a moderately free move- 
ment of the bowels. After paying due attention to the regulation of the 
secretory functions, and the removal of coincident functional disturbances 
as far as they may belong to individual cases, the medicines which have 
seemed to have most direct influence in controlling the disease have been 
moderately large doses of glycerine, acidulated with citric acid, taken in a 
very dilute form, usually about an hour after each meal, and a full dose of 
ergotine with codeine at bed time. I usually direct patients to commence 
the use of glycerine acidulated with citric acid in doses of two cubic cen- 
timeters (fl. 3ss) in an ordinary tumbler one third full of water, gradually 
increasing the doses of glycerine until, in the course of two weeks, they 
reach four cubic centimeters or an ordinary teaspoonful. You must be sure 
that the glycerine is taken well diluted with water. In many instances I 
have directed, at the same time, a pill of two decigrams (gr. iii) of ergotine 
after breakfast and at bed time, adding to the dose at bed time from 
one to two centigrammes (gr. J to %) of codeine. Before I com- 
menced the use of ergotine and codeine I had given a considerable 
number of diabetic patients every night a pill containing from six to 
nine centigrammes (gr. i to iss) of opium with the one centigramme 
(gr. 1-6) of sulphate of copper in addition to the medicine they were tak- 
ing during the day, and with a decided beneficial influence. In a very 
strongly marked case of diabetes, in a man aged about thirty years, who 
was employed in one of the railroad depots of the city, after taking 
glycerine acidulated with citric acid as I have indicated, apparently with 
a moderate degree of benefit during the first two weeks of treatment, 
and when he had reached the dose of four cubic centimeters three times 
a day, the remedies seemed to induce an attack of vomiting and diarrhoea 
almost as severe as an ordinary attack of cholera morbus. The discharges 
were at first thin and copious, but in the course of twenty-four or thirty- 
six hours, became more painful, small in quantity, and mingled with mucus 
and a little blood, much resembling dysenteric evacuations. The glycerine 
was immediately discontinued, but it required eight or ten days for the 
patient to recover from the severe irritation that had supervened in the 
mucous membrane of the alimentary canal. During all this severe irrita- 
tion in the alimentary canal, the excretion of urine was but little more 
than natural in amount, and afforded very little evidence of the presence 
of sugar. As the patient recovered from his intestinal difficulty, he found 
that the quantity of urine began again to increase, with a correspondingly 
increased proportion of sugar. He was again put upon the use of the 
glycerine, being more cautious to have it largely diluted when taken and 
the dose a little smaller than had been the case before. Irritation of the 
bowels was also repressed by a moderate opiate at night. The disease 
was again checked without any untoward symptoms, and in about three 
months he apparently recovered good health, and returned to his ordinary 
occupation. Twice after that there were symptoms of relapse, and the 
same treatment resorted to again restored him, after which he remained 
apparently free from the disease and pursued his occupation almost unin- 
terruptedly for a period of nearly ten years. During the greater part of that 
time he used but little of the more starchy vegetables. He adopted as 
his permanent diet what might be called a meat diet, with very little use 
of the tuberous roots, such as beets, turnips and potatoes, but otherwise in- 
dulged in nearly the ordinary diet provided upon the family table. I 



TREATMENT. 859 

have obtained the same result, without the intercurrent period of irritation 
of the bowels, in at least six or eight cases of well marked diabetes 
meilitus. But this is a small number compared to the whole number of 
oases that have come under my observation, and consequently demon- 
strates but a small ratio of cures. I have also treated a number of pa- 
tients on the principle of aiding in 'the assimilative processes more es- 
pecially, and consequently have made diligent and protracted use of the 
various preparations of pepsin, lactic acid and the lactates, peroxide of 
hydrogen, antacids and carminatives, but in very few instances with any 
perceptible influence over the progress of the disease. The only prepara- 
tion of pepsin, or the class of agents addressed directly to the supposed 
improvement of digestion and assimilation, which has been in a marked de- 
gree beneficial in my hands is a preparation of rennet, made by macerat- 
ing a good specimen of rennet, preferably from the pig, in dilute acetic 
acid orvineo-ar, therebv making a dilute acetated tincture of the rennet. 
It may be prepared extempore by cutting up fresh rennet and putting it 
into the vinegar, allowing it to stand two or three days, occasionally shak- 
ing or stirring it up. The patient can take of this preparation doses of 
four cubic centimeters (fl. 3') just after each meal, gradually increasing 
it till from eight to twelve cubic centimeters (fl. 3ii to 3iii) are taken at a 
dose. This mode of treatment was first proposed, so far as my knowledge 
extends, by Dr. Joseph Jones, now of New Orleans, who at the time of pro- 
posing this treatment was practicing in Georgia, and in connection with a 
medical school in that State. He reported the successful treatment of 
several cases of the disease with the rennet prepared in extempore as I 
have already suggested. I found it to diminish the amount of urine 
secreted and to palliate some of the more distressing symptoms of the pa- 
tient in the advanced stages of the disease, but its influence appeared to be 
purely palliative or temporary, having no curative effect. Another remedy 
which has been recommended, and which, in the early stage of the 
disease, may be resorted to once or twice a week perhaps with ad- 
vantage, is the pilocarpine or the fluid extract of jaborandi. What- 
ever preparation is used should be in such doses as to produce the 
specifjc effect of the drug in a moderate degree without carrying it 
far enough to produce too great a degree of depression. Creating a 
moderate flow of saliva and sufficient diaphoresis to moisten the skin for 
a time and repeat this in connection with other treatment once or twice 
a week has been found to exert a favorable modifying influence over the 
progress of the disease. As the patient's strength fails, and he becomes 
tormented day and night with inordinate thirst, and yet so weak and tired 
as to make life a burden, and it has become apparent that the disease has 
passed beyond any reasonable expectation of control, remedies should be 
given more with a view of palliating the patient's symptoms, and ameli- 
orating his suffering than for any other purpose. He should then be al- 
lowed a liberal quantity of drink, persuading him to use, apart of the time 
at least, milk whey and buttermilk rather than exclusively water, and giv- 
ing him some one of the preparations of opium, of which perhaps codeine 
is the best so long as it can be made to answer the purpose. For the pur- 
pose of allaying restlessness, lessening consciousness of suifering, and es- 
pecially to procure some degree of sleep at night, opiates in some form 
become indispensable in the advanced stage of the disease. This form of 
diabetes, as well as that of diabetes insipidus, has been treated with elec- 
tricity, galvanism and electro-magnetism, in almost all modes of application 



860 ENURESIS. 

and degrees of perseverance, but with very little apparent influence over 
the progress of the disease.* 

Enuresis. — By enuresis I mean incontinence of urine, which, al- 
though having no connection with or analogy to diabetes in any form, is, 
nevertheless, a very troublesome affection, particularly apt to be met with 
in children under ten years of age. Some cases are met with at a later 
period of youth, or up even to adult life. The affection to which I more 
particularly allude is not absolute incontinence, or constant dribbling of 
urine, for most of the patients during the day will be able, by passing their 
urine frequently, to avoid actual dribbling, or wetting their clothes. 
Many of them, however, especially when under ten years of age, are not 
sufficiently vigilant, and often while at play, either in doors or out, will al- 
low more or less urine to escape, and cause some soiling of their clothing 
almost every day. But the chief trouble with this class of patients comes 
at night. A majority of them, after the utmost pains are taken to have 
them fully empty the bladder on going to bed, will soon fall asleep and 
remain so from one to four hours, when the urine passes involuntarily 
while they are profoundly asleep, thereby wetting the bed and everything 
around them. This will be renewed in many cases two or three times in 
the course of every night, rendering themselves and the bed very untidy, 
and giving a great annoyance to mothers and nurses. Of course there 
are cbffe.ent degrees of frequency of urination in this class of cases dur- 
ing the night as well as day. In some instances it will occur but once, 
and occasionally one or two nights will escape. In others, as already re- 
marked, the bed will be saturated three or four times between the ordi- 
nary hours of retiring at night and rising in the morning. It is a very 
co.nmon occurrence for parents to be annoyed with this circumstance, and to 
treat the child as though it was a matter the child could control. And not 
infreq lent y chastisements have been inflicted upon the unfortunate chil 
dren, with a view of teaching them better manners than to be wetting the 
bed every night. But I have never known an instance in which chastise- 
ments succeeded in effecting a cure, but many in which they aggravated the 
difficu'ty. The more timid patients become, and the more their minds are 
subject to dread or fear the less control the nerves have over the sphinc- 
ter muscles of the bladder. Consequently all such harsh and cruel treat- 
ment of these children should be avoided. It is the duty of the physician 
to give heed to these cases whenever parents call their attention to them; 
and instead of treating it as a matter of course, or a habit, careful inquiry 
should be made into the circumstances that operate upon the patients, their 
mode of eating and drinking, the condition of their digestive organs, and 
especially the condition of the nervous system, for the purpose of ascer- 
taining the causes* on which the difficulty depends. With many of them 
it will be found that it is mainly associated with imperfect digestion of 
food and habit of drinking water indiscriminately a dozen times in the 
day, and frequently up to the time of retiring to bed. The blood is thus 
supplied with an undue proportion of its watery element, and the urin- 
ary secretion increased. In other instances, and perhaps in the greater 

*Atthe recent meeting ofthe American Medical Association in Washington, an interesting raper on 
"The Milk Tre itment of Disease" was read in the Section on Practice of Medicine and Materia Medica, 
by Dr James Tyson, of Phila lelphia, in which he nses the following language : " As to diabetes 
meliitus, it is now generally conce ted that no measures nre so efficient in removing the sugar from 
the urine, and relieving other symptoms, as the dietetic; and of the dietetic treatment none has 
been so promptly efficient in my nan Is as an exclusive miik diet. 7 ' He prefers skimmed milk, and 
requires dult patients to take from 130 to 390 cubic cent meters (fl. oz. iv to oz. xii) every two or 
three hours. Very recently several cases of diabetes meliitus have been reported in the medical 
perio iicals as successfully treated with bromide of arsenic, in a paper on this disease read in the 
Medical Section of the American Medical Association at its recent meeting, by Dr. Austin Flint, 
Jr . the bromide of arsenic is referred to as beneficial in many eases. He gives the remedy in 
doses of three to five minims three or four times a day, largely diluted with water. 



TREATMENT. 8G1 

number, the difficulty will be found to consist in a morbid condition of 
the nervous system, more especially with the excito-motor or reflex sys- 
tem, which governs the sphincters of the body. It will be found that, 
while most of these patients are of a nervous temperament, excitable and 
easily frightened, there is less than the natural amount of involuntary 
action in the sphincter muscles, and there is also more or less of imperfect 
digestion of food, causing „he gastric secretion to be unduly acid and the 
urine more stimulating to the coats of the bladder, and disturbing to the 
whole nervous system. 

Very many of this class of patients, especially those in early childhood, 
are paler than natural, showing a decided predominance of the watery 
element of the blood, and deficiency of the red corpuscles, together with 
a markedly excitable nervous temperament. Nearly all of these cases 
can be cured if the physician will go earnestly about ascertaining the 
temperament, habits and influences which may be operative in produc- 
ing and perpetuating the malady, and adjusting the rational remedies for 
their correction. It is desirable to select such remedies for steady, regu- 
lar use from day to day as are calculated to diminish the morbid excita- 
bility of the coats of the bladder, and to improve directly the tone and 
efficiency of the excito-motory nervous system. In other words, the rem- 
edies should embrace a nerve tonic in connection with something uhai will 
diminish the sensitiveness of the mucous membrane lining the bladder and 
urinary passages. In some of the slighter cases accompanied by de- 
rangement of the digestive organs, nothing more is required than to have 
a watchfulness kept over the amount of drink that the patient takes in 
the latter part of the day and evening, the avoidance of indigestible food, 
and the regular administration of some one of the alkaline carbonates suf- 
ficient to neutralize any excess of acid in the stomach and the secretions, 
thereby rendering the urine more free from irritating qualities. Where 
the habit is'more fixed and the child has become more pale, or anaemic, I 
have derived much benefit from the use of preparations of iron as tonics, 
and moderate doses, in some instances, of ergotine, and in others, of 
strychnia or nux vomica, as remedies designed to directly increase tne 
tone of the nervous system. I have frequently prescribed a mixture of 
glycerine and syrup of the iodide of iron in the proportion of three parts 
of the first to one of the last; of which mixture from ten to twenty minims 
may be given three times a day, largely diluted with water, to children 
from five to seven years of age. With the evening dose I have often 
added five minims of a good fluid extract of ergot with advantage. But 
whatever may be the remedies adopted, if they are adjusted in suitable 
doses and are calculated to lessen the sensitiveness of the urinary organs, 
and the irritating quality of the urine, whenever it may contain an excess 
of uric acid or uric acid salts, and at the same time to exert a tonic an 1 
invigorating influence upon the general tone of the organic nervous sys- 
tem, there will seldom be a failure to remove this annoying difficulty with- 
in a few weeks. Recently the following formula has been used in a con- 
siderable number of cases with unusual success: 

Extracti Rhus Aromat. Fluidi 
Extracti Ergot Fluidi 
Tincturae Nucis Vomicae 
Simple Elixir 

Mix. Give to a child five years of age from ten to fifteen minims 
three times a day, in a little sweetened water. In all cases due attention 
should be given to the supply of good food, pure air, proper clothing and 
out-door exercise. 



45 


c. c. 


^iss. 


30 


c. c. 


fi. 


15 


c. c. 


3iv. 


60 


c. c. 


?". 



862 THERAPEUTICS OF ALCOHOL. 



LECTURE XCII. 

Alcoholic Liquids as Therapeutic Agents: What indications are they actually capahle of ful- 
filling in the treatment of disease ? Ana what substitutes, if any, can be employed by tuu physician 
with advantage to his patients ? 

GENTLEMEN: I take pleasure in complying with your request to oc- 
cupy the hour that remains for completing the present course of 
lectures, in the presentation of my views concerning the therapeutic 
value of alcoholic liquids in the practice of medicine.* 

Alcoholic liquids, as derived from the fermentation of various fruits 
and vegetable substances, have been known and used from an early period 
in the history of our race. Being derived from the grape or fruit of the 
vine chiefly, the name vinum, or wine, was naturally applied to all these 
liquids, until some time in the seventh century, when a liquid obtained 
from the fermentation of corn began to be called beer by the Saxons. 

During the prevalence of the Alchemists' or Arabian school of chem- 
istry, in the eleventh century, the vinous liquids in use began to be sub- 
jected to distillation, by which the active intoxicating constituent was 
obtained in a concentrated form, to which was applied the name " spirit 
of wine," and afterward the word "alcohol." This last word appears to 
have been first used by the Arabians to designate an impalpable cosmetic 
powder used by the women of that day. It was afterward applied to 
various subtle powders, and finally to spirit of wine. The first really 
scientific use of the term "alcohol" with which we are acquainted was 
by Lemert in his chemistry, published in 1698. For a long period after 
the discovery of spirit of wine or alcohol, it was used only as a solvent or 
menstruum in the preparation and preservation of other substances, while 
the fermented liquids continued to be used as drinks. The impure and 
diluted alcohols derived from distillation of fermented liquids, known as 
brandy, gin, rum and whisky, are of modern origin, having been intro- 
duced into use within the last two or three centuries. Although we have 
a large variety of beverages derived from fermentation and distillation, 
known as wines, beers and distilled spirits, yet ethylic, or absolute ether, 
universally known under the name of alcohol, constitutes the active, con- 
trolling ingredient in them all. The amount of this alcohol in the fer- 
mented drinks, called wines, beers, ales, etc., varies from four to twenty 
per cent., while in the distilled spirits, called brandy, whisky, rum and 
gin, it constitutes from fifty to seventy-five per cent. Separate the alco- 
hol from all thesa liquids, and the remainder would be capable of produc- 
ing very little more effect on the human sj'stem than pure water. The 
juniper in gin, the hop in beer, and the vegetable acids and fecula in 
wines, are in quantities too small to exert any important influence, and 
hence may be omitted from our further consideration. 

When we speak of alcohol, therefore, or of the effects of alcohol, 
throughout the remainder of this paper, we mean to include all alcoholic 
liquids, whether fermented or distilled. Until analytical and organic 
chemistry had made sufficient progress to show the composition of the 
more common articles of food and drink, no efforts were made to explain 
the special or physiological action of alcohol on the human system. All 
liquids containing it were simply regarded as cordial or stimulant, and 
capable of supporting strength and life. When the chemico-physiolog- 

*This was the closing lecture in the Practitioners' Course for 1884, and was given in compliance 
with a special request of the class in attendance. 



THERAPEUTICS OF ALCOHOL. 863 

ieal school of investigators, with Baron Liebig at its head, developed the 
fact that all alimentary substances were capable of being arranged into 
two classes, the nitrogenous and carbonaceous, they very naturally adopt- 
e 1 the theoretical idea that the former, when taken into the system, were 
appropriated to the nourishment of the tissues, wl.ile the latter united 
with oxygen by a species of combustion, resulting in the development of 
animal heat and carbonic acid gas, and hence were familiarly styled 
M respiratory food." 

Alcohol, being one of the purest of the carbonaceous class, and espe- 
cially rich in carbon and hydrogen, was at once assigned a place at the 
head of the list of respiratory foods, and of supporters of animal heat. 
"VV hen taken into the living system it was supposed to unite rapidly with 
the oxygen received through the lungs, evolving heat, and leaving "as re- 
sultants carbonic acid gas and water; in this way its supposed heating and 
stimulating effects were explained. 

The simplicity of the explanation, coupled with the high authority of 
Liebig, caused it to be almost universally accepted, although resting on 
a purely theoretical basis, without a single experimental fact for its sup- 
port. It was not Ions:, however, before Dr. Prout, of London, ascertained, 
by direct experiment, that the presence of alcohol in the human system 
directly diminished the amount of carbonic acid gas exhaled from the 
lungs, and consequently there could be no combustion or oxydation of the 
alcohol by which it was converted into carbonic acid and water. Dr. Percy* 
and others, by examination, found that alcohol taken in a, dilute form into 
ihe stomach, was taken up without change of composition, and carried 
with the blood into all the organs and structures of the body, and that 
its presence could be easily detected by the proper chemical tests. The 
chemico-physiologists, however, still assuming that alcohol, being a hydro- 
carbon, must necessarily be used for maintaining temperature and respira- 
tion, suggested that the union of its elements with oxygen might be 
such as to result in forming acetic acid or aldehyde instead of carbonic 
acid gas. Hence they still sustained the popular belief that alcoholic 
drinks were capable of increasing both the temperature and strength of 
the human body. In the mean time, the process of experimentation 
went on. Dr. Bt)cker,f of Germany, by a well-devised and carefully 
executed series of experiments, proved that the presence of alcohol in the 
living system, actually diminished the sum total of eliminations of effete 
matter daily; and consequently, that its presence must retard those molec- 
ular changes by which nutrition, secretion and elimination are effected. 
In 1850, the writer of this paper prosecuted an extensive series of experi- 
ments to determine the effects of different articles of food and drink on 
the temperature of the body, and on the amount of carbonic acid excreted 
from the lungs. These experiments proved conclusively that, during the 
active period of digestion after taking any ordinary food, whether nitrog- 
enous or carbonaceous, the temperature of the body is always increased; 
but after taking alcohol in the form of either fermented or distilled drinks, 
the temperature begins to fall within half an hour, and continues to de- 
crease for from two to three hours. The extent and duration of the re- 
duction of temperature was in direct proportion to the amount of alcohol 
taken, ]3rovided the effect was not complicated by the coincident ingestion 
of digestible food. The results of this series of experiments were embodied 
in a paper read to the American Medical Association in May, 1851. J A few 

* An Experimental Inquiry Concerning the Presence of Alcohol in the Ventricles of the Brain, 
etc.; London, 1839. 
t Beit rage zur Heilkunde, Crefeld, 1849. 
jcee Northwestern Medical aud Surgical Journal for 1851. 



SGI THERAPEUTICS OF ALCOHOL, 

years later, the experimental researches of Lallemand, Perrin and Duroy,* 
proved conclusively that alcohol, when taken into the stomach, was not 
only absorbed and carried with the blood into all the organs and tissues of 
the body, but also that it was eliminated as alcohol, unchanged chemically, 
from the lungs, skin and kidneys. The experiments of Prout were re- 
peated, and his results confirmed by Sandras and Bouchardet, of France, 
W. A. Hammond,f myself and others of this country. Those of Bftckor 
were carefully repeated and varied by Anstie, of England, and Hammond, 
of this country. My own in reference to the effects of alcohol on animal 
heat have been repeated, and the results confirmed by a large number of 
observers, among whom are Drs. Richardson,J Anstie and Hammond. 
Those of Lallemand, in reference to the elimination of alcohol, have been 
equally confirmed, except the claim that the amount eliminated is not 
equal to the whole quantity taken. 

It is conceded by all investigators that when alcoholic liquids are taken 
into the stomach or in any other way administered, the alcohol is rapidly 
absorbed into the blood, circulates with it throughout all the tissues of the 
body, and may be detected in the form of alcohol, both in the blood and 
in the structures of the various organs. All agree, also, that it is elimi- 
nated through the various eliminating structures, as the skin, lungs, kid- 
neys, etc. These simple facts, when observed in regard to the behavior 
of any other substance, are regarded as amply sufficient to prove that 
the substance so acting is not alimentary in its nature, but foreign to tha 
system. 

But so strong is the predisposition to find some important rs3 for alco- 
hol in the human system, caused by customs and habits of thought 
through many generations, that the most vigorous tests and calculations 
have been made to ascertain whether some part, at least, of the alcohol 
taken might not be retained, and if not used directly for nutrition of the 
tissues, certainly converted into some kind of force or energy. The late 
Dr. Anstie, who followed up the investigation of this question with the 
most commendable perseverance, came to the conclusion that an average 
sized adult in ordinary health was capable of retaining about 45 grammes 
(fl. Jiss) of pure alcohol in the twenty-four hours, admitting that when- 
ever more than this was taken in the time specified, it re- appeared in the 
evacuations or was eliminated unchanged. From this it has been very 
generally assumed, not only that the amount named may be retained, but 
that it must of necessity be so used or re-combined as to evolve some 
kind of sustaining force. For a long time it was claimed the retained 
alcohol underwent oxydation, and evolved heat. When this was fully 
demonstrated to be erroneous by the direct application of the clinical 
thermometer, by all experimenters from my own in 1850 to the present 
time, § it was then assumed that its consumption resulted either directly 
or indirectly in the evolution of nerve force. But here again the crucial 
test of direct experimental observation soon showed, that so far as the 
motor and sensory nerve and muscular functions are concerned, both 
were diminished in direct ratio to the quantity of alcohol taken. 

While the presence of alcohol in the blood slightly increases the fre- 
quency of the action of the heart, it renders its systole shorter and quick- 
er, while it simultaneously so modifies the vaso-motor nerve influence 
over the whole system of smaller vessels and capillaries as to retard the 

*DuRole de 1'A.lcool et des Anesthesiqu93 dans I'Organism, Paris, 1860. 

1 Physiological Memoirs, pp. 43 to 50. 
Diseases of Modern Life, pp 220 ani 230, New York, 1883. 
Even the extended observations of Dr. Parkes and Count Wallowicz, led only to negative re- 
sults in tn is regard. 



THERAPEUTICS OF ALCOHOL. 865 

current of blood in them and to cause their manifest dilatation. Conse- 
quently, the sphygnu graphic line is made to rise more abruptly with the 
cardiac systole and fail still more quickly in the diastole, with a slight 
wavy or unsteady character of the line before the next systole, giving to 
the tracing characters closely resembling the pulse line of typhoid 
fever.* 

The increased frequency of the pulse led Dr. Parkes and Count Wal- 
lowicz to make an interesting mathematical calculation of the supposed 
increased amount of work done by the heart under the influence of alcohol 
as compared with the normal standard. 

Their results under eight days daily use of alcohol, gave an average of 
over 14,000 beats per day more than without the alcohol, from which they 
estimated that the heart did an amount more of work per day equal to 
the lifting of from fifteen to twenty tons one foot. The language used by 
these observers in stating the foregoing results, has created the manifest- 
ly erroneous impression, that the heart, under the influence of alcohol, 
is made to do so much more actual efficient work in the circulation 
of the blood; whereas the increased frequency of the beats is more than 
counterbalanced by the diminished influence of the vaso- motor nerves on 
the coats of the smaller vessels, causing them to become unnaturally full 
from the retardation of the blood currents in them.f The truth is that 
under the influence of alcohol in the blood, the systolic action of the heart 
loses in sustained force in direct proportion to its increase in frequency, 
until by simply increasing the proportion of alcohol, the heart stops in dias- 
tole, as perfectly paralyzed as are the coats of the smaller vessels throughout 
the system. This was admirably demonstrated by the recent experimental 
investigation of Professor- Martin, of the Johns Hopkins University, Mary- 
land, on the effects of different proportions of alcohol on the action of the 
heart of the dog,J and of Drs. Sidney Ringer and Harrington Sainsbury, 
to determine the relative strength of the different alcohols, as indicated by 
their influence on the action of the heart of the ffog.§ These latter emi- 
nent experimenters say in closing their report on the action of the alcohols, 
" that by their direct action on the cardiac tissue, these drugs are clearly 
paralyzant, and that this appears to be the case from the outset, no stage 
of increased force of contraction preceding." Professor Martin states the 
results obtained by him as follows: " Blood containing one eighth per cent. 
hy volume of absolute alcohol has no immediate action on the isolated 
heart. Blood containing one fourth per cent, by volume, that is two and 
a half parts per thousand of absolute alcohol, almost invariably remarka- 
bly diminishes, within a minute, the work done by the heart; blood con- 
taining one half per cent, always diminishes it, and may even bring the 
amount pumped out by the left ventricle to so small a quantity, that it is 
not sufficient to supply the coronary arteries." Professor Martin estimates 
one fourth per cent., or two and a half parts per thousand, of the blood of 
an adult man, weighing 150 pounds, to be only fifteen cubic centimeters 
(fl. 3iv), an amount only equal to that contained in an ordinary gla^s of 
brandy or whisky.|| These investigations of Professor Martin, directly 
corroborated by those of Drs. Ringer and Sainsbury, complete the series 
of demonstrations needed to show the actual effects of alcohol on the car- 
diac, as well as the vaso-motor nerves, and also on the direct contractibil- 
ity of the muscular structure, when supplied with blood containing all 

* See Chicago Medical Examiner, Vol. VIII, p. 522, 1867. 
t Diseases of Modern Life by B. W. Richardson, p. ?16. 
% See Journal of the American Medical Association, Vol. 1, page 307. 

| See The Practitioner, London. May, 1^83, and Journal of American Medical Association, Vol. 1, 
p ge272. 
|j Maryland Medical Journal for September, 1883. 

55 



866 THERAPEUTICS OF ALCOHOL. 

gradations in the relative proportion of alcohol, leaving no longer a refuge 
for the idea, popular both in and out of the profession, that alcohol in any 
dose is capable of increasing, even temporarily, the lorce or efficiency of the 
heart's action. It is certain, therefore, that if a small proportion of the 
alcohol taken in the various fermented and distilled liquids is retained in 
the living body, or can not be actually reproduced in the eliminations 
within a limited time, such retained portion is neither used for the evo- 
lution of heat, the increase of nerve force, the efficiency of muscular 
contraction, nor yet for quickening molecular movements in the processes 
of nutrition, disintegration and secretion. Consequently, the assump- 
tion that if any part of the alcohol taken is retained for a time, at least, 
it must from necessity be converted into some kind of force or energy, is 
not sustained by any known facts, either of scientific experiment or of 
clinical experience. On the contrary, it acts in the same direction as 
chloroform, ether, and all the other members of the same chemical group 
of substances, namely, as an anaesthetic to nerve sensibility, a relax- 
ant of muscular tone or contractibility, and a retarder of molecular 
movements in the tissues: these effects being produced in direct ratio to 
the amount taken, relatively to the whole weight of the individual taking 
it. That the action of alcohol in the human system is in all respects sim- 
ilar, except in being slower, to that of chloroform and ether, was fully dem- 
onstrated by the direct investigations of Dr. Anstie, who concludes this 
part of the subject with the following important declaration: u A general 
review of the phenomena of alcohol-narcosis enables me to come to one 
distinct conclusion, the importance of which appears to be very great, 
namely, that (as in the case of chloroform and ether) the symptoms which 
are so commonly described as evidences of excitement, depending on a 
stimulation of the nervous system preliminary to the occurrence of narco- 
sis, are in reality an essential part of the narcotic, that is, the paralytic 
phenomena."* So far from being justified in the common assumption that 
all the alcohol, not capable of being detected in the eliminations during 
twenty- four or forty-eight hours after it is taken, is converted into some 
kind of force, there is positive proof that it remains unchanged, and can 
be detected in the living tissues long after it ceases to be detected in 
either the breath, perspiration or urine. Thus the same author just 
quoted, says on page 368: "Nothing is more plainly proved by M. M. 
Lallemand, Duroy and Perrin, than the fact that long after the latest 
periods at which any of the alcohol absorbed can be recognized in the 
breath, the urine, or the sweat, unchanged alcohol in notable quantities 
can be recognized in the blood and tissues of the alcoholized animal. M. 
Baudot justly observes that there is no necessity to suppose that this sub- 
stance must be transformed immediately^ if transformed at all, in the or- 
ganism." And T may add, in view of the fact that the most varied and scru- 
tinizing researches of different investigators have entirely failed to find 
any products of such transformation, either in the form of matter or force, 
there is no probability that such transformation ever does take place; 
but that the retained alcohol is held simply by a strong affinity for the 
albuminoid constituents of the blood and tissues, retarding by its pres- 
ence the natural affinities and movements of such constituents, and being 
detached and eliminated by the slow process of disintegration, and disap- 
pearance of the atoms by which it is held. It is exactly this retained 
alcohol that causes in the habitual moderate drinker, those slow, but cer- 
tain deteriorations of structure in the liver, kidneys, cardiac and vascular 

* See Stimulants and Narcotics, Their Mutu 1 Relations, etc., by Francis E. Anstie, M. D., M. R, 
C. P., page 357. 



THERAPEUTICS OF ALCOHOL. 807 

walls and structures, generally described by pathologists under the 
head of fatty and atheromatous degenerations. That part of the alcohol 
taken which finds ready elimination, contributes to the direct anaesthetic 
effect, and more prominent temporary functional disturbances, but leaves 
little permanent impression on the living structures. 

From all the foregoing considerations we may formulate the following 
propositions: 

First. That alcohol, when taken diluted in the form of fermented or 
distilled spirits, is rapidly absorbed without change, carried into the blood, 
and with that fluid brought in contact with every structure and part of 
the human body. 

Second. That while circulating in the blood, its presence retards those 
molecular or atomic changes which constitute nutrition, disintegration and 
secretion, and on which the phenomena of life depend. 

Third. That its presence in the living system retards the elimination 
of waste matter, impairs nerve sensibility, lessens muscular excitability 
and contractibility, and lowers the temperature of the body. 

Fourth. That a large part of the amount taken is rapidly eliminated 
with the various excretions, and there is no evidence whatever that such 
part as may be retained a longer period, is either assimilated or converted 
into any form of force. 

These propositions are as well established as any facts in the domain of 
physiology, or in the whole field of natural science, and they point with 
all the clearness and force of a mathematical demonstration to the con- 
clusion that alcohol is in no sense food; neither furnishing material for 
the tissues, nor fuel for combustion, nor yet generating either nervous or 
muscular force. Having thus determined, experimentally, that alcohol is 
neither food nor a generator of force in the living body, the question re- 
curs, what are its positive effects when taken in the ordinary manner? 
I answer, simply those of an anaesthetic and organic sedative. Like ether 
and chloroform, its presence diminishes the sensibility of the nervous sys- 
tem and brain, thereby rendering the individual less conscious of all out- 
ward and exterior impressions. This diminution of sensibility, or anaes- 
thesia, is developed in direct ratio to the quantity of alcohol taken, and 
may be seen in all stages, from simple exemption from all feeling of 
fatigue, pain, and idea of weight, exhibited by ease, buoyancy, hilarity, 
etc., to that of complete unconsciousness, and loss of muscular power. It 
is this anaesthetic effect of alcohol that has led to all the popular errors and 
contradictory uses which have proved so destructive to human health and 
happiness. It has long been one of the noted paradoxes of human action, 
that the same individual would resort to the same alcoholic drink to warm 
him in winter, protect him from the heat in summer, to strengthen when 
weak or weary, and to soothe and cheer when afflicted in body or mind. 
With the facts now before us, the explanation of all this is apparent. The 
alcohol does not relieve the individual from cold by increasing his tem- 
perature, nor from heat by cooling him, nor from weakness and exhaustion 
by nourishing his tissues, nor yet from affliction by increasing nerve 
power, but simply by diminishing the sensibility of his nerve structures, 
and thereby lessening his consciousness of impressions, whether from cold 
or heat, or weariness or pain. In other words, the presence of the alcohol 
has not in any degree lessened the effects of the evils to which he is ex- 
posed, but has diminished his consciousness of their existence, and there- 
by impaired his judgment concerning the degree of their action upon him. 

It is this property of alcohol to produce that sense of ease, buoyancy 
and exhilaration, arising from a moderate diminution of nerve sensibility, 



868 THERAPEUTICS OF ALCOHOL. 

that gives it the fascinating and delusive power over the human race 
which it has wielded so ruinously for centuries gone by. But while the 
presence of alcohol diminishes the sensibility of the nervous structure, it 
also retards all the molecular changes, thereby diminishing the activity of 
nutrition, secretion, elimination and the evolution of heat, constituting a 
true organic sedative. When taken in small quantities, repeated daily, 
the individual usually slowly increases in weight, not from increased nutri- 
tion, but from retarding the waste and retaining the old atoms longer in 
the tissues. By some investigators this power to retard atomic changes 
and consequently to retain the old atoms has been regarded as equivalent 
to nutrition, or the actual assimilation and addition of new atoms. It is 
on this basis that Dr. Hammond and a few others persist in representing 
alcohol as indirect food.* The fallacy of such claim, and its mischievous 
tendency, will be fully apparent by reference to one of the plainest laws 
governing living animal matter. The law is, that all the phenomena of 
animal life are associated with and dependent on atomic changes, and 
that each individual cell or aggregation of bioplasm constituting an or- 
ganic atom, has its determinate period of growth, maturity and dissolution. 
Hence, to introduce into the living system any agent that will retard 
atomic change, is equivalent to retarding the phenomena of life. And if 
by retarding the atomic changes, cells or atoms are retained in the tissues 
longer than the natural duration of their activity, such retention may in- 
crease the bulk and weight, but in the same ratio it embarrasses the tis- 
sues with the presence of material which is constantly becoming inert and 
tending to degeneration. Consequently, the individual who thus increases 
his bulk and weight by taking just enough of the weaker alcoholic drinks 
daily to retard the processes of secretion and waste, in the same propor- 
tion diminishes his activity, his power of endurance, and his ability to 
resist the effects of morbid agents of every kind. This is abundantly 
illustrated by the thousands of beer and wine drinkers, who from twenty 
to twenty-five years of age were muscular, active, capable of any reason- 
able endurance, with a weight of 150 pounds, but who, after moderately 
retarding atomic changes and retaining: old atoms by the daily use of wine 
or beer, have acquired a weight of 20U pounds or more, and have lost their 
muscular activity and endurance to such an extent that an active exercise 
of twenty minutes would make them entirely out of breath. It is this 
sedative effect of alcohol on the organic or molecular changes in the 
tissues, retaining; waste and effete matter, that ought to have been prompt- 
ly disintegrated and thrown out, which impairs the vital properties, and 
predisposes or prepares the system to yield to morbid influences of any 
kind to which it may be exposed. And especially does this sedative effect 
of alcohol on the organic changes, when maintained by a moderate and 
continued use of the article, favor those degenerative changes which re- 
sult in tubercular, caseous, and fatty deposits in the lungs, liver, kidneys, 
heart and arteries of the brain, and in materially shortening the duration 
of life. It is the same interference with the processes of nutrition an i 
waste, only exerted more actively, that causes gastritis and delirium tre- 
mens in the excessive drinker of distilled spirits. If you ask for the special 
modus operandi of alcohoi, how it produces its anassthetic and sedative 
effect when taken into the human system, I answer, chiefly by its strong 
affinity for water and albumen. The two last named substances exist in 
the blood and all the tissues of the body, and for them alcohol has a strong 
chemical affinity. Hence, when it is present in the blood, it attracts the 

* A Ureatise on Hygiene, with Special Reference to Military Service, I860, p. 35. 



THERAPEUTICS OF ALCOHOL. 86 J 

water from the blood corpuscles, causing them to become more or less 
corrugated, and inclined to adhere to one another as described by Dr. 
llichardson, o!" London, and diminishing the capacity of the blood to ab- 
sorb oxygen or other gases from the air in the lungs; and by its strong 
affinity lor the albumen of the tissues, it retards the play of vital affinity 
between that substance and the other materials with which it is in contact, 
thereby retarding the molecular changes as already described. The 
paralyzing effect exerted on the vaso-motor as well as cerebro-spinal nerv- 
ous structures by which sensibility is impaired, is owing partly to the 
direct amcsthetic properties of the alcoho:, and partly to the diminished 
interchange of oxygen for carbonic acid gas in the process of respiration. 
That a part of the alcohol should be retained for a considerable length of 
time in the system by the affinities just mentioned, is very probable. 
Hence the late Dr. Anstie may have been correct in claiming that it was 
not all eliminated from the system within any limited period of time, and 
yet its retention would afford no proof that it was either appropriated as 
food or for the generation of force. 

Ou the contrary, the catalytic influence of its presence retards both. 
If we scan the whole domain of physiology and pathology in connection 
with the logical deductions from the experimental researches by parties 
widely separated by time, space, nationality and language, we shall be 
forced to the conclusion that alcohol, as found in any or all of the fer- 
mented and distilled drinks, is neither stimulating, strengthening, nor 
nourishing to the human system, but simply anaesthetic and sedative. 

What then are the therapeutic indications they are capable of fulfilling 
in the treatment of disease? First. By the anaesthetic properties of the 
alcohol they contain, they are capable of diminishing nerve sensibility 
and muscular force, in the same manner as other well-known anaes- 
thetics. 

But from the slower development of the effects of the alcohol, and the 
still slower disappearance of those effects, the liquids containing it are 
far inferior for all practical anaesthetic purposes, to chloro.orm, ether or 
nitrous oxide, and are consequently seldom used in that cap icity, except 
to relieve pain and promote sleep in certain conditions of nervous unrest. 
And here, again, they are far less efficient and more liable to secondary 
bad consequences than the bromides, chloral, and the numerous class of 
milder anodynes and antispasmodics familiar to every intelligent phy- 
sician. 

Second. By the power of alcohol to retard the evolution of heat in 
retarding molecular changes in the tissues, the liquids containing it may 
be used as antipyretics when the temperature is too high, and to retard 
the processes of waste when these are too rapid. But the antipyretic in- 
fluence of alcohol is so feeble in comparison with the proper application 
of water to the surface, or with the internal administration of sulphate of 
quinia, salicylic acid, digitalis, etc., that no one thinks of using it for an- 
tipyretic purposes. 

The power of alcoholic liquids to retard the molecular changes in the 
blood and tissues, and thereby lessen the rapidity of tissue change, really 
constitutes the basis on which rests the use of a large part of what is 
prescribed by the profession at the present day in the treatment of the 
sick. In this, however, there are involved two fallacies of much im- 
portance. The first arises from the failure to discriminate between the 
loss of flesh and strength from a failure or diminution of the processes of 
assimilation and nutrition by which the natural tissue waste is replaced 
by new matter, and the loss of flesh and strength from simple excess of 



870 THERAPEUTICS OF ALCOHOL. 

rapidity in the processes of disintegration or tissue wastj while the repara- 
tive processes remain natural. 

The second consists in the assumption, that retarding molecular move- 
ments in such manner as to lessen the rapidity of natural change or dis- 
integration of tissue is equivalent to the maintenance of tissue integrity 
by the assimilation and addition of new matter; the falsity of which I 
have already pointed out. 

There is, indeed, no more mischievous error existing either in or out 
of the profession, at this time, than that of regarding the loss of fhsh, 
whether from disease or overwork, as generally due to increased disin- 
tegration instead of diminished nutrition. The first existing alone as a 
primary morbid condition is exceedingly rare, while the latter is present, 
to some extent, in nearly all the morbid conditions met with. And yet 
alcohol is, even theoretically, applicable only to cases of the first, while 
practically, as shown by clinical experience, it is not adapted to the suc- 
cessful treatment of either of the conditions named. For while its 
presence in the blood retards tissue change, it does it by equally retard- 
ing the molecular movements concerned in the processes of assimilation, 
nutrition and secretion. Consequently while its first impression is often 
delusively beneficial, its continuance for one, two or three weeks almost 
invariably develops a diminution of appetite for food, an impairment of 
the digestive function, or manifest derangements in the excretory func- 
tions. 

An infinitely better method of promoting nutrition and maintaining 
the healthy balance between it and waste, consists in a full supply of pure 
air, a sufficient supply of plain digestible food, and the judicious regula- 
tion of the hours of exercise and rest, both mental and physical. To 
supplement these with any form or quantity of alcohol, is entirely super- 
fluous; and to attempt to substitute the latter in the place of any one of 
the former, only leads more speedily and certainly to disastrous failure. 
In cases requiring any other aid to the nutritive processes and the main- 
tenance of general tonicity, besides pure air, good food, and a proper reg- 
ulation of exercise and rest, the hypophosphites of calcium, sodium and 
iron, the lactophosphates of calcium and iron, the ordinary preparations 
of iron, and the bitter infusions may be resorted to with advantage. 

The two therapeutic indications I have now passed in review are the 
only ones that can be founded on the known and demonstrated effects of 
alcohol on the functions and structures of the human body. But there 
are two others supposed to exist by a large portion of the profession and 
of the community. One of these is founded on the supposed ability of the 
alcohol to strengthen the action of the heart and sustain the circulation 
generally. It is to fulfill this, that the alcoholic liquors are so extensively 
used in the typhoid and many other low forms of febrile disease. And yet 
you have already seen that the entire series of facts derived from the whole 
field of experimental investigation, proves that the presence of alcohol ex-; 
erts a paralyzing influence over the whole vaso-motor system of nerves and 
finally paralyzes the heart itself, and wherever the proper tests have been 
applied, the results of experimental research have been corroborated by 
clinical experience. It is now thirty-five years since I commenced the 
direct clinical study of the effects of alcohol as a remedial agent. I 
have used the spygmograph and all other means of testing the strength ot 
the heart and the efficiency of the circulation, in every variety of the low 
forms of febrile disease coming under my observation, and I have never 
yet found an instance in which it increased the cardiac force or the 
efficiency of the general circulation. But I have seen many cases in 



THERAPEUTICS OF ALCOHOL. 871 

which it so impaired the vasomotor influence as to greatly increase 
passive congestion in the lungs and other vascular structures, and that, too, 
while its anaesthetic influence in quieting restlessness, caused the patients 
to appear comfortable, and to say they were better, even up to the time of 
relaxation of the sphincters and the occurrence of involuntary discharges. 
I have repeatedly, under such circumstances, stopped entirely the admin- 
istration of alcoholic remedies and in their place given strychnine and the 
mineral acids, alternated with suitable doses of digitalis, caffeine, or in- 
fusion of coffee with milk, and wheat-flour and milk gruel for nourishment, 
with the most satisfactory results. Strychnia, digitalis, convallaria, 
cactus grandiflora, caffeine and theine, are true vaso-motor and cardiac 
tonics, with none of the paralyzing influences of alcohol, and none of the 
secondary tissue degenerative tendencies possessed by the latter. 

Tney are consequently admirably adapted to fulfill the indications pre- 
sented in the lower types of acute general diseases, for which alcoholic 
preparations have so long been prescribed injuriously On a false basis. 
The second popular therapeutic indication is founded on the equally false 
idea, that alcohol is capable of acting, at least as a temporary stimulant, 
in arousing nerve sensibility and sustaining cardiac action in cases of threat- 
ened syncope, shock, and other forms of sudden and severe depression or 
exhaustion. But the same fatal objection lies against its use for fulfilling 
this indication as in the immediately preceding one; namely that the 
alcohol acts as a paralyzant and anaesthetic from the first drop to the last, 
and in no sense as a stimulant. If you ask me how it happens that a 
remedy that does, not only no good, but is directly calculated to do harm, 
can so long and universally maintain its reputation, both in and out of the 
profession, in such cases, I answer, that it does so solely by reason of 
two facts: First, that ninety and nine of every hundred cases of threat- 
ened or actual syncope, shock, nervous prostration and sinking, for which 
alcoholic liquids are so hurriedly used, would and do recover just as quick- 
ly and more certainly, if simply placed at rest in fresh air without a drop 
of alcohol in any form. But as such cases are sometimes severe enough 
to require some prompt and judicious treatment, we have in the corbonate 
and aromatic spirits of ammonia, and the preparations of camphor, far 
more speedy and efficient remedies for immediately arousing sensibility, 
especially when aided by a few sudden dashes of cold water upon the face 
and chest, and in the caffeine, digitaline, convallaria, etc., the proper 
cardiac tonics for restoring permanent steadiness and force to the circula- 
tion. I speak the more positively on this subject, geutlemen, because, 
for more than thirty years past I have faithfully tested the correctness of 
the sentiments I have given you in relation to the therapeutic effects and 
uses of alcoholic liquids in an ample clinical experience both in hospital and 
private practice; and during all that time I have found no case of disease 
and no emergency arising from accident, that I could not treat more success- 
fully without any form of fermented or distilled liquors than with. It is easy 
to see that the anaesthetic properties of alcohol can be made available by 
an intelligent and skillful physican to meet a very limited number of in- 
dications in the treatment of some cases that will come before him. But 
the same intelligence and skill will enable him to select other remedies 
capable of meeting the same indications more perfectly, and, with less 
tendency to secondary bad effects. I have no hesitation, therefore, in 
stating that for the attainment of the highest degree of success in the 
management of all forms of disease, whether acute or chronic, we need no 
form of fermented or distilled alcoholic drinks. Pure alcohol for chemical, 
pharmaceutical and manufacturing purposes, is all that is necessary or valu- 



872 THERAPEUTICS OF ALCOHOL. 

able to be derived from this class of agents. And whoever will boldly make 
the trial, will find that his patients, of every kind, will make better prog- 
ress, on good air and simple nourishment, without any admixture of 
alcoholic liquids, than they will with such addition. In other words he will 
find that the supposed benefits of this class of agents in medicine, are as 
illusory as they are in general society, and that the words of the wise 
man are worthy of careful consideration when he says: " Wine is a mocker 
and strong drink is raging, and whosoever is deceived thereby is not 



INDEX 



A BERNETHY. JOHN. 
j\ on mental derangements, 798 
Acidum Benzoicum. 

diphtheria, 173 

scarlet fever, 233 

scrofulous periostitis, 267 
Acidum Carbohcum. 

bronchitis, 4 '6, 409, 415 

carcinoma, 282, 285. 

cerebro-spinal meningitis, 352 

cholera, epidemic, 674 

cholera morbus, 656, 658 

diphtheria, 173, 175 

dysentery, 565, 570 

dyspepsia, 837, 841 

enteritis, 540 

fever, yellow, 150 

fever, relapsing, 137, 138 

hydrophobia, 782 

inflammation of mucous membrane 
nose, 379, 380 

parasites of intestines, 848 

periostitis, scrofulous, 267 

phthisis pulmonalis, 466 

pneumonia, 437 

stomatitis mercurial, 496 

stomatitis scorbutic, 502 

syphilis, 288 

trichinosis, 849 

ulcer, gastric, 521 

variola, 217. 218 
Acidum Citricum. 

diabetes, 858 
Acidum Galicum. 

diabetes, 852 

dysentery, 565 

hemorrhages, 693 

nephritis, 626 

fever, typhoid, 119 

ulcer, gastric, 525 
Acidum Hydrobromicurn. 

cholera morbus, 656 
Acidum Hydrochloricum. 

diphtheria, 174 

fever, typhoid, 101, 116 

glossitis, 506 

heart, fatty degeneration of, 833. 

scarlatina, 234 
Acidum Hydrocyanicum. 

dyspepsia, 837^ 



of 



Acidum Lacticum. 

diabetes mellitus, 859 

diphtheria, 176. 

laryngo-tracheitis, 389 
Acidum Nitricum. 

dysentery, 567 

roseola, 246 

syphilis, 2S8 

variola, 218 
Acidum Salicylicum. 

dengue, 77. 

diphtheria, 173 

fever, relapsing, 137 

parasites, intestinal, 348 

rheumatism, 298, 299 
Acidum Sulphuricum Aromaticum. 

cholera morbus, 656 

cholera, epidemic, 673 

dysentery, 564, 566 

enteritis, 540 

fever, typhoid, 118 

influenza, 73. 
Acidum Sulphurosum. 

diphtheria, 172, 173 

erysipelas, 161 
Acidum Tannicum. 

diabetes, 852 

hemorrhages, 694 

nephritis, 626 
Aconitum. 

aneurism, 834 

apoplexy, 709 

endocarditis, 486 

fevers, eruptive, 212 

fever, intermittent, 191 

fever, relapsing, 191 

myocarditis, 486 

pleuritis, 444 

pneumonia, 428 

scarlatina, 234 

spinal meningitis, 358 

tonsilitis, 509 
Addison's Disease, 276 
Addison, Thomas 

on Addison's disease, 275 

on anaemia, pernicious, 276 
Adenitis, 258 

pathological anatomy, 261 

scrofulous inflammation of mucous 
membranes, 262 



(873) 



874 



INDEX. 



Adenitis, treatment of, 26G 

symptoms, 258 

treatment, 261 
^Efcheris Nitrosi, Spiritus. 

cholera morbus, 658 

diphtheria, 173 

dysentery, 565 

dropsies, 683 

enteritis, 538, 539 

erysipelas, 160 

levers, eruptive, 212 

lever, typhoid, 105, 116 

hsernaturia malarial, 203 

hepatitis, 601 

nephritis, 616 

peritonitis, 579 

pleuritis, 444, 445, 446 

pneumonia. 430 

scarlatina, 237 

thrush, 493 
JEther Sulphuricus. v 

ulcer, gastric. 523 
Aii- 
Compressed. 

bronchitis, 409 
Rarefied. 

bronchitis, 409 
Aitkens, William 

on fever, 35 . 

on fever, yellow, 146 

on rubeola, 237 
Alcohol. 

acute general diseases, 871 

apoplexy, 712 

cerebro-spinal meningitis, 350 

cholera, epidemic, 675 

diphtheria, 172 

fevers, 870 _ _ 

fever, pernicious. 199 

fever, typhoid, 106 

fluxes, "641 

gout, 309 

insomnia, 764 

physiological action, 863, 867 

spinal meningitis, 366 

tetanus, 774 

therapeutic agent, 86 3 

therapeutic indications, 869 
Alkalies. 

diabetes, 851 

diabetes mellitus, 861 

dyspepsia, 838 
Allen, J. A. 

on erysipelas, 154 

on meningitis, 342, 351 
Aloe. 

apoplexy, 711 

bronchitis, 408 

exophthalmic goitre, 831 

fever, intermittent, 195 

fever, relapsing, 195 

fever, tvpnoid, 120 

fluxes, 643 

inflammation of mucous membrane 
of nose, 380 

phthisis, 466 



Aloe. 

rheumatism, 301 

ulcer, gastric, 523 
Alteratives. 

fever, typhus, 127 

leucocythemia, 272 
Alumen. 

diabetes, 852 

dysentery, 565 

hemorrhages, 693 

laryngo-tracheitis, 390 

stomatitis follicular, 495 

thrush, 493 
Ames, S., 

cerebro-spinal meningitis, epidemic, 
349, 349 
Ammoniae Spiritus Aromatic. 

cholera morbus, 659 

syncope, 871 
Ammonii Acetatis, Liquor. 

bronchitis, 405, 407 

diphtheria, 173 

dysentery, 565 

enteritis, 538, 539 

fever, eruptive, 212 

fever, typhoid, 105, 116 

hepatitis. 601 

nephritis, 616 

peritonitis, 579 

pleuritis, 444, 445, 446 

pneumonia, 430 

scarlatina, 234 
Ammonii Bromidum. 

apoplexy, 711 

epilepsy, 736 

hysteria, 760 

insomnia, 764 

meningitis, 338 

mental derangements, 806 

roseola, 246 
Ammonii Carbonas. 

bronchitis, 407 

cerebro-spinal meningitis, 351 

diphtheria, 172, 175 

peritonitis, 581 

pneumonia, 431 

scarlatina, 234 

syncope, 871 

variola, 217, 218 
Ammonii Chloridum. 

diphtheria, 174 

fever, intermittent, 195 

fever, relapsing, 195 
Ammonii Iodidum. 

scrofulous periostitis, 266 
Ammonii Murias 

bronchitis, 406 

hepatitis, 601, 602 

laryngo-tracheitis, 389 

phthisis, 469 

pneumonia, 429, 436. 

scarlatina, 234 
Ammonii Nitras. 

asthma, 413 
Ammonii Phosphas. 

gout, 307 



INDEX. 



875 



Ammonii Valerianae. 

epilepsy, 744 
hysteria. TOO 
Amy! Nitrite. 

asthma. 4I"> 

asthma, spasmodic, 818 

hydrophobia, 760 

roseola. 246 
Anaemia, pernicious, 274 
Anderson. 

scarlet lever, 233 
Andral, Gabriel. 

anaemia, pernicious, 275 

fever, typhoid, 97 
Andrews, Edmund 

chronic general diseases, 25tf 

pneumonia, 432 
Aneurism, 834 
Angina pectoris, 824 

causes, 826 

pathology, 825 

prognosis, 826 

symptoms, 824 

treatment, 826 
Anise seed. 

dyspepsia, 842 

miguet, 492 
Anodynes. 

angina pectoris, Hoffman's, 828 

perityphli is, 546 
Anstie, Francis E. 

alcDhol, 866, 869 
Antacids. 

diabetes mellitus, 859 
Antimonii et potassii tartras. 

asthma* 413 

bronchitis, 406 

laryngo-tracheitis, 390 

phthisis, 469 

pneumonia. 429 
Antimonii Vinum. 

bronchitis, 405 
Antipyretics. 

fever, relapsing, 138 

fever, typhoid, 114 
Antiseptics. 

fever, relapsing, 137 

fever, typhoid, 127 

hydrophobia, 780 
Aphonia. 

symptoms, 820 

treatment, 822 
Apomorphia. 

hydrophobia, 780 

laryngo-tracheitis, 390, 392 
Apoplexy. 

diagnosis, 706 

symptoms, 703 

treatment, 708 
Argenti Nitras. 
~ apoplexy. 732 

diphtheria, 173 

dysentery, 565, 570, 571 

enteritis. 540, 541 

erysipelas, 162, 163 

fever, typhoid, 112, 117, 121 



Argenti Nitras. 

laryngo-tracheitis, 390, 392 

meningitis, :i:!s 

stomatitis follicular, 494 

ulcer, gastric, 522, 524, 525 
Arsenici Bromidum. 

diabetes mellitus, 860 
Arsenicum. 

leucocythemia 
Arthritis deformans, 310 

symptoms, 310 

treatment, 311 
Asc'epias tuberosa. 

bronchitis, 408 

influenza, 73 
Aspiration. 

dropsies, 683; pericarditis, 478 

peritonitis, 581, 589 

pleuritis, 446 
Asalcetida. 

catalepsy, 749 

hysteria, 760 
Asthma, 410. 

germs in, 415 
Asthma, spasmodic, 815. 
Astringents 

cholera, epidemic, 675. 

fever, typhoid, 112, 119 
Atropia. 

cholera, epidemic, 674 

delirium, tremens, 795 

fever, pernicious, 202 

neuralgia, 768 



BACTERIA. 38, 71, 79, 80 
erysipelas, 160, 166 

fever, relapsing, 133 
Badham. 

bronchitis, 393 
Bailey, N. B. 

erysipelas, 166 
Baudot, M. 

alcohol, 866 
Bard, John. 

fever, yellow, 149 

meningitis, 341 
Bard, Samuel. 

erysipelas, 163 
Barii Chloridum. 

meningitis, 338 
Barker. 

fever, relapsing, 132 
Barnes. 

fever, pernicious, 202 
Bartlett, E. 

fever, typhus, 122 

simple continued fever, 165 
Bartholow Roberts. 

carcinoma, 285 

fever, simple continued, 65 

heat exhaustion, 785 

pneumonia, 434 
Barthez, M. 

pneumonia, 427 



876 



INDEX. 



Bartletr, I. 

fever, periodical, 181 
Bastian. 

1 neumonia, 434 
Baths. 

endocarditis, 486 

epilepsy, 734 

inflammation of mucous membrane 

of nose, 380 
myocarditis, 486 
nephritis, 619, 626, 628 
pleuritis, 466 
rheumatism, 301 
Beale, L. 15 
Beardsley, Z. N. 

erysipelas, 163, 1C4 
Beaugency. 

vaccinia, 223 
Beismer. 

anaemia, pernicious, 275 
Bell, John. 

erysipelas, 163 
Belladonna. 

apoplexy, 711 

cerebro-spinal meningitis, 352, 353 
colic, bilious, 551 
diaphoresis, 644 
diphtheria, 174 
fever, typhoid, 110, 119 
glossitis, 506, 509 
hydrophobia, 782 
laryngo-tracheitis, 392 
mumps, 248 
peritonitis, 588 
scarlatina, 234, 235 
stomatitis, 496 
tetanus, 774; typhlitis, 543 
Bennett Hughes. 

ansemia, pernicious, 273 
inflammation, 319 
leueocythemia, 2c8 
Benzoin. 

bronchitis, 408 
hysteria, 572 
Bernard, Claude. 

action of potassii chloras, 101 
diaphoresis, 640 
fibrin, 13 
Biermer. 

bronchitis, 398 
Bigelow, Jacob. 

action of medicines, 45 
Bilious colic, 547 
Bismuthi Subnitras. 
diaphoresis, 644 
duodeno-hepatitis, 534 
dysentery, 571 
enteritis, 541 
fever, typhoid, 122 
rheumatism, 299 
ulcer, gastric, 523 
Bitters. 

fever, intermittent, 195 
fever, remittent, 195 
Bleeding. 

cerebro-spinal meningitis, 350 



Bleeding. 

fever, intermittent, 191 
fever, remittent, 191 
fever, yellow, J 49 
laryngo-tracheitis, 389 
spinal-meningitis, 358 
Blisters. 

bronchitis, 406 
duodeno-hepatitis, 533 
erysipelas, 162 

laryngo-tracheitis, 390 
peritonitis, 580 

pleuritis, 445, 446 

pneumonia, 429 

rheumatism, 299 

ulcer; gastric, 523 
Bocker. 

alcohol, 863 
Bontius. 

cholera epidemic, 661 
Bouchardet, M. 

alcohol, 864 
Brain. 

inflammation of, 321 
Brainard, Daniel. 

carcinoma, 282 
Brayera. 

parasites, intestinal, 848 
Bretonneau, M. 

erysipelas, 163 
Bright, Richard. 

nephritis, 621, 624 
Bromides. 

apoplexy, 710 

cerebro-spinal meningitis, 351 

epilepsy, 733 

insomnia, 764 

terrors, night, 765 
Brjmine. 

diphtheria, 172, 174 

dysentery, 5 1 

enteritis, 542 

epilepsy, 737 

fever, typhoid, 122 
Brown, John. 

theorv of disease, 23 
Bronchitis, 393 

acute, 395 
Broussais, F. J. V. 

bronchitis, 393 

theory of disease, 23 
Brown- Sequard, M. 

epilepsy, 731 
Buchu. 

fever, pernicious, 203 
Buchwald. 

fever, relapsing, 133 
Buck, Gurdon. 

laryngo-tracheitis, 392 
Budd. 

fever, typhoid, 82, 93 

laryngo-tracheitis, 392 
Buhl. 

erysipelas, 166 
Byford. W. H. 

erysipelas, 157 



INDEX. 



>4 i 



Blood. 

constituents of, 12 



p ACTUS. 

\J cardiac irritability, 824 

endocarditis, 486 

fatty degeneration, 833 

insomnia, 765 

myocarditis, 486 
Caffeine, dysentery, 567 

peritonitis, 581 

syncope, 871 
Calcii Hypophosphis. 

bronchitis, 408 

diphtheria, 178 

fever, intermittent, 195. 

fever, remittent, 195 
Calcii Hyposulphis. 

fevers, eruptive, 210 

scarlatina, 233 

variola, 217 
Calcii Iodidum. 

arthritis deformans, 311 

chronic general diseases, 256 

phthisis, 436, 465, 466, 469 

rubeola, 240 
Calcii Lactophosphas. 

bronchitis. i03 

cerebro-spinal meningitis, 354 

chorea, 745 

chronic general diseases, 256 

diphtheria, 178 

fever, periodical, 193, 195 

fever, typhoid, 120 

phthisis, 436, 465, 466, 469 

rubeola, 240 

spinal meningitis, 367 

stomatitis scorbutic, 502 
Calcii Oxidum. 

arthritis deformans, 311 
Calcii Sulphis, 

diphtheria, 172 . 

erysipelas, 167 

fever, eruptive, 210 

fever, pernicious, 193 
Calorification, 25, 28 
Campbell, H. F. 

dengue, 74 
Camphor. 

catalepsy, 749 

cerebro-spinal meningitis, 353, 354 

diphtheria, 172, 175, 176 

fever, relapsing, 137 

fever, typhoid, 119 

nephritis, 615 

peritonitis, 581 

roseola, 246 

syncope, 871 

terrors, night, 766 

variola, 217, 218 
Camphor, monobromated. 

paraplegia, 723 
Cancrum Oris, 503 
Cannabis Indica. 

hydrophobia, 780 



Cannabis Indica. 
rheumatism, 301 
paraplegia, 723 

tetanus, 774 
Cantharides. 

cerebro-spinal meningitis, 353 
Carbonates. 

endocarditis, 485 

myocarditis, 485 
Carcinoma, 278 

anatomical structure, 279 

causes, 278 

diagnosis, 280 

history, 278 

prognosis, 281 

treatment, 281 

varieties, 279 , 
Cardamom seeds. 

indigestion, 842 
Cardiac irritability, 822 

symptoms, 822 

treatment, 8^3 
Carditis, En do and Myo, 478 

diagnosis, 483 

prognosis, 483 

symptoms, 479 

treatment, 484 
Carey. . 

ansemia, pernicious, 276 
Carminatives. 

diabetes mellitus, 859 

indigestion, 838 
Carpenter, W. B. 

fibrin, 12 
Catalepsy, 746 

diagnosis, 748 

pathology, 748 

prognosis, 748 

symptoms, 746 

treatment, 749 
Cathartics, 36 

apoplexy, 709 

hepatitis, 562 

nephritis, 628 

recto- colitis, 561 

scarlatina, 234 
Catlin, B. H. 

cerebro-spinal meningitis, 350 

cerebritis, 330 
Cerii Oxalas. 

gastritis, 523 

ulcer, gastric, 523 
Charcoal. 

indigestion, 838 
Charcot, J. M. 

epilepsy, 731 

hystero-epilepsy, 762 

leucocythemia, 268 

pneumonia, 434 

spinal meningitis, 364 
Cheviot, M. 

spinal meningitis, 
Chloral. 

bronchitis, 413 

cerebro-spinal meningitis, 351 

chorea, 744 



873 



INDEX. 



Chloral. 

delirium tremens, 794 

epilepsy, 733 

hvdrophobia, 780 

hysteria, 760 

insomnia, 764 

meningitis, 338 

mental derangements, 806 

nephritis, 615 

roseola, 246 

sunstroke, 789 

terrors, night, 766 

tetanus, 774 
Chlorine. 

diphtheria, 172 
Chloroform. 

bronchitis, 415 

convulsions, 753 

diphtheria, 174 

fevers, periodical, 191 

fever, typhoid. 118 

hydrophobia, 780 

inflammation mucous membrane of 
nose, 380 

laryngismus stridulus, 818 

neuralgia, 768 

sunstroke, 789 

tetanus, 774 
Cholera, epidemic, 661 

anatomical changes, 667 

causes, 662. 

complications and sequelae, 675 

diagnosis, 669 --.— 

history, 661 

prognosis, 670 

prophylaxis, 676 

symptoms, 655 

treatment, 671 
Cholera morbus, 644 

anatomical changes, 653 

etiology, 645 

pathology, 654 

prognosis. 653 

prophylaxis, 645 

symptoms, 650 

treatment, 655 
Chorea, 738 

causes, 738 

clinical history, 738 

diagnosis, 742 

pathology, 741 

prognosis, 742 

treatment, 742 
Christison. 

fever, relapsing, 132 
Chronic general diseases, 249 

etiology, 251 

names, 249 

pathology, general, 249 

pathological inferences, 254 

treatment, 254 
Cimicifuga Racemosa. 

bronchitis, 458 

chorea, 745 

rheumatism, 299 

spinal meningitis, 367 



Cinchona. 

adenitis, 262 

cerebro spinal meningitis, 350 

cholera, ep.demic, 671 

chorea, 745 

leucocythemia, 272 

nephritis, 627 

periostitis, scrofulous, 266 

stomatitis, 493, 496 

syphilis, 289 
C.nchonidia, 761 

sunstroke, 790 
Clark, Alonzo. 

fever, yellow, 147 
Clark N. Hayes. 

scarlatina, 233 
Classification, 48 
Climate. 

bronchitis. 410 

phthisis, 436 
Cline. 

vaccina, 221 
Clymer, Meredith. 

fever, relapsing, 132 
Cochineal. 

roseola, 246 
Codia. 

bronchitis, 405, 406, 408, 413 

diabetes mellitus, 858 

fluxes, 644 
Coffee. 

dysentery, 431 

pneumonia, 567 
Cohn, B. 

erysipelas, 166 

fever, relapsing, 133 
Colchicum. 

apoplexy, 713 

bronchitis, 407, 413 

chorea, 745 

gout, 307, 308, 309 

rheumatism, 300, 301 
Cold. 

apoplexy, 709, 710 

convulsions, 753 

spinal meningitis, 358 

sunstroke, 788 

tetanus, 775 
Colic. 

bilious, 547 

symptoms, 547 

treatment, 548 
Colocynth. 

fluxes, 643 

gout, 308 
Condie, D. Francis. _ 

cho'era, epidemic, 671 
Conheim, Julius. 

inflammation, 319 
Conium. 

adenitis, 262 

epilepsy, 736 

hepatitis, 601, 602 

laryngo- tracheitis, 392 

meningitis, 337 

nephritis, 626. 



INDEX. 



871) 



Hornum. 

paraplegia, 722 
peritonitis, 588 
spinal meningitis, 367 

syphilis, 289 
tetanus, 774 

Connolly, J. 

mental derangements, 798 
Constipation. 835 
Contagion or contagium, 63 
Convallaria. 

aneurisms, 834 

cardiac irritability, 824 

endocarditis, 486 

fatty degeneration, 833 

insomnia, 765 

myocarditis. 

syncope, 871 
Convulsions, 750 

treatment, 753 

varieties, 750 
Copaiba. 

roseola, 242 
Copeiand, James, 38 

fever, 53. 57 

miasms, 38 
Coptis. 

stomatitis, 490, 493, 500 
Cormack. 

fever, relapsing, 132 
Cora us Florida. 

fever, pernicious, 192, 194 
Corrigan. 

pneumonia, 434 
Corson, H. 

scarlatina., 233 
Counter Irritation 

duodeno-hepatitis, 534 

larvngo-tracheitis, 392 

peritonitis, 588 

spinal meningitis, 358, 067 
Craigie. 

fever, relapsing, 132 
Crudeli, I. 

fever, periodical, 181 
Cullen. 

theory of disease, 23 

fever, 53 
Cupping. 

cholera, epidemic, 671 

nephritis, 614, 615, 617 

spinal meningitis, 367 

sunstroke, 788 

tetanus, 775 
Cupri Sulphas. 

diphtheria, 173 

diabetes mellitus, 858 

gastritis, 524 

larvngo-tracheitis, 390, 392 

stomatitis, 494 

ulcer, gastric, 524 
Curare. 

hydrophobia, 780 
Currie, James. 

antipyretics, 103 

scarlatina, 233 



D\NA. C. L. 
pachymeningitis, 323 
Davidson, J. P. 

fever, pernicious, 201, 202 
Davis, F. H. 

bronchitis, 397 

fevers, eruptive, 206 

variola, 218 
DeClat. 

carcinoma, 282 
Delirium Tremens, 790 

anatomical changes, "<92 

diagnosis, 793 

prognosis, 793 

symptoms, 790 

treatment, 794 
Degner. 

cholera, epidemic, 661 
Dengue, 74 

diagnosis, 76 

etiology, 76 

history, 74 

prognosis, 75 , 

progress, 75 

symptoms, 75 

treatment, 76 
Depletion. 

inflammation, 320 
Dexter, G-. J. 

erysipelas, 155 
Diabetes Insipidus, 850 

anatomical changes, 851 

prognosis, 851 

symptoms, 850 

treatment, 851 
Diabetes Mellitus, 852 

diagnosis, 856 

pathology, 855 

prognosis, 857 

symptoms, 852 

treatment, 857 
Diaphoretics, 36 

inflammation, 320 
Diarrhoea, serous, 644 
Dickson, S. H. 

dengue, 44 
Diet. 

gout, 309 
Diuretics , 36 

inflammation, 320 
Digitaline. 

apoplexy, 710 

syncope, 871 
Digitalis. 

aneurisms, 834 

angina pectoris, 828 

aphonia, 822 

apoplexy, 709, 710, 713. 

bronchitis. 406 

cardiac irritability, 824 

cholera morbus, 658 

delirium tremens, 794 

dropsies, 683 

dysentery, 565 

endocarditis, 484, 486 

epilepsy, 733, 736 



880 



INDEX. 



Digitalis. 

exophthalmic goitre, 831 

fatty degeneration of heart, 833 

fever, relapsing, 138 

fever, typhoid, 106, 118, 119, 120 

hemorrhages, 692 

hepatitis, 601 

insomnia, 764 

meningitis, 336 

mental derangements, 806 

myocarditis, 484, 486 

nephritis, 615, 616, 617, 618, 619, 626 

pericarditis, 477 

peritonitis, 581, 588 

pleuritis, 445, 446 

pneumonia, 430, 431 

rheumatism, 299 

scarlatina, 234 

sunstroke, 789 

terrors, ni 'ht, 766 
Diphtheria, 163 

causes, 164 

convalescense, 177 

diagnosis, 171 

history, 163 

pathology, 172 

prognosis, 172 

prophylaxis, 177 

sequelae, 177 

symptoms, 167 

treatment, 172 
Disease, definition of, 19 
Disintegration, 25, 26 

conditions of, 26 
D'Orta. 

cholera, epidemic, 661 
Douglass, William, 
erysipelas, 163 
Dover's Powder, 
bronchitis, 407 
cerebro-spinal meningitis, epidemic 

352 
diphtheria, 176 
duodeno-hepatitis, 533, 534 
enteritis, 539 
erysipelas, 160 
fever, relapsing, 137 
inflammation of mucous membrane of 

nose, 378 
meningitis, 338 
nephritis, 615 
pleuritis, 445 
pneumonia, 429 
rheumatism, 298,300 
lubeola, 240 
spinal meningitis, 358 
tonsillitis, 509 
variola, 217 
Drake, Daniel. 

ce. -euro-spinal meningitis, epidemic, 

346 
chronic general diseases, 253 
fever, 54 

fever, intermittent, 188 
fever, pernicious, 196, 200 
fever, typhoid. 81. 90 



Drake, Daniel. 

inflammation of mucous membrane of 

air passages, 372, 374 
pneumonia, 416 
Dropsies, 678 

causes, 678 

prognosis, 681 

treatment, 682 

varieties, 678 
Dubois, A. 

fever, relapsing, 132 
Dummler. 

fever, relapsing, 13j? 
Dunglison, Robley. 

on febrine, 12 
Duodeno- Hepatitis. 

anatomical changes, 529 

diagnosis, 530 

prognosis, 531 

symptoms, 527 

treatment, 532 
Duroy, M. 

alcohol, 864, 866 
Dysentery, 551 

anatomical changes, 553 

causes, 551 

diagnosis, 560 

prognosis, 560 

symptoms, 553 

treatment, 561 
Dysentery, chronic, 568 

prognosis, 569 

treatment, 570 
Dyspepsia, 835 



EARLE, C. W. 
rotheln, 241 
Eberle, John. 

fever, 53 

fever, intermittent, 195 

fever, remittent, 195 

fever, simple, continued, 68 
Eberth. 

fever, typhoid, 83 
Edwards Milne. 

fever, pernicious, 200 
Ehrenberg. 

fever, relapsing, 133 
Elaterium. 

dropsies, 683 

nephritis, 628 
Electricity. 

arthritis deformans, 311 

catalepsy, 749 

diabetes mellitus, 859 

diphtheria, 178 

epilepsy, 749 

epilepsy, hystero, 762 

exophthalmic goitre, 832 

hemorrhages, 694 

leucocythemia, 723 

spinal meningitis, 358, 368. 
Emetics, 36 

bronchitis, 407 

cholera, epidemic, 675 



INDEX. 



881 



Emetics* 

scarlatina, 224 
Enemas. 

colic, bilious, 564 
enteritis, 539 
erysipelas, 162 
meningitis, 336 
peritonitis, 579 
perityphlitis, 546 
pneumonia, 428 
recto-colitis, 564 
typhlitis 
Engel. 

fever, relapsing, 132 
Enteritis, 584 

anatomical changes, 537 
causes, 534 
diagnosis, 538 
symptoms, 534 
treatment, 538 
varieties, 534 
Enuresis, 860 

symptoms, 860 
treatment, 861 
Epilepsy, 724 

anatomical changes, 731 
causes, 729 
symptoms, 725 
treatment, 732 
varieties, 724 
Erb, W. H. 

spinal meningitis, 362 
Ergot. 

cerebro-spinal meningitis, 352 
diabetes insipidus, 852 
enteritis, 867 
exophthalmic goitre, 831 
hemorrhages, 692 
meningitis, 338. 
nephritis, 626 
spinal meningitis, 658 
Ergotine. 

apoplexy, 710, 712 
diabetes mellitus, 858 
enuresis, 861 
iever, typhoid, 119 
fluxes, 643, 644 
hydrophobia, 
nephritis, 615, 619 
phthisis pulmonalis, 469 
pneumonia, 430 
tetanus, 774 
ulcer, gastric, 525 
Erigeron Canadensis. 

diarrhoea serous, 659 
Erysipelas, 154 
causes,. 155 
diagnosis, 159 
history, 154 

pathological anatomy, 159. 
prognosis, 159 
prophylaxis, 162 
special anatomy, 160 
symptoms, 156 
treatment, 160 
Etiology, 37 

56 



Eucalyptus. 

bronchitis, 408, 414, 415 

inflammation mucous membrane of 
nose, 380 

laryngismus stridulus, 818 
Evacuents. 

abuse of, 27 

cholera, epidemic, 675 
Examination of the sick, 40 
Expectorants, 36 



PACHS, F. a 

J? fever, pernicious, 203 

Fearn. 

fever, pernicious, 201 
Felix, Mas. 

parasites, intestinal, 848 
Fenner, E. D. 

cerebro-spinal meningitis, 346 
cholera, epidemic, 665 
dengue, 74, 76 
fever, yellow, 145 
Ferri chloridum. 

cerebro-spinal meningitis, 353 
diphtheria, 173, 175 
erysipelas, 161, 163 
fever, yellow, 151 
hemorrhages, 693 
laryngo-tracheitis, 390 
nephritis, 616, 626 
scarlatina, 234, 237 
variola, 217 
Ferri citras. 

diphtheria, 178 
fevers, periodical, 193 
gout, 309 
hysteria, 761 
Fern et Quiniae Citras. 

syphilis, 290 
Ferri Hypophosphas. 

fever, periodical, 195 
Fern Iodidum. 
enuresis, 861 
fluxes, 643 
Ferri Lactas. 

carcinoma, 282 
diphtheria, 176 
laryngo- tracheitis, 389 
Ferri Lactophosphas. 

leucocythemia, 273 
Ferri A Titras. 

cholera morbus, 659 
Ferri Persulphas. 

fever, typhoid, 119 
hemorrhages, 692 
ulcer, gastric, 524 
variola, 218 
Ferri Phosphas. 

bronchitis, 408 
Ferri Pyrophosphas. 

leucocythemia, 273 
Ferri Subcarbonas. 
dysentery, 571 
enteritis, 541 
fever, typhoid, 122 



.882 



INDEX. 



Ferri Subcarbonas. 

fluxes, 644 
Ferri Sulphas, 
apoplexy, 711 
bronchitis, 408 
constipation, 840 
erysipelas, 162 
exophthalmic goitre, 831 
fever, periodical, 194 
fever, typhoid, 120 
gastritis, 523 
gout, 308 _ 
inflammation of mucous membrane of 

nose, 380 
phthisis pulmonalis, 466 
rheumatism, 301 
stomatitis follicular, 495 
Ferrum. 

convulsions, 755 
diabetes insipidus, 853 
diphtheria, 172 
hysteria, 761 
leucocythemia, 268 
Fever. 

blood, 59 
definitions, 53 
heat, 58 
self-limited, 60 
rarieties, 57 
Fevers— continued, 61 
kinds, 62 
causes, 62 
Fever, eruptive, 204 

anatomical changes, 209 
causes, 205 
history, 204 
names, 204 
pathology, 207 
treatment, 210 
Fever, irritative, 64 
Fever, intermittent, 186* 
Fevers, periodical, 178 
causes, 180 

general pathology, 182 
history, 178 
varieties, 182 
Fever, pernicious, 196 
Fever, relapsing, 131 
causes, 133 
diagnosis, 135 
history, 131 
pathology, 136 
prognosis, 135 
prophylaxis, 138 
symptoms, 134 
treatment, 137 
Fever, remittent, 188 
Fever, simple — continued, 64 
etiology, 66 
history, 64 

pathological anatomy, 66 
symptoms, 65 
treatment, 67 
Fever, typhoid, 77 
complications, 119 
diagnosis, 91 



Fever, Typhoid, 
etiology, 78 

pathological anatomy, 95 
prognosis, 92 
symptoms, 86 
treatment, 102 
Fever, typho-malarial, 203 
Fever, typhus, 122 
causes, 123 
diagnosis, 126 
history, 122 
pathology, 127 
prognosis, 126 
prophylaxis, 128 
symptoms, 125 
treatment, 127 
Fever, yellow, 139 
causes, 140 
diagnosis, 145 
history, 139 
pathology, 147 
prognosis, 1^6 
prophylaxis, 151 
symptoms, 144 
treatment, 148 
Fibrin. 

function, 12 
Fischel. 

fever, typhoid, 83 
FlaxSeed. 

nephritis, 614 
Flint, Austin, Jr. 

diabetes mellitus, 860 
Flint, Austin, Sr. 

anaemia, pernicious, 275 
cholera morbus, 645 
dengue, 74 . 
dysentery, 555. 
fever, 55, 59 

fever, relapsing, 132, 133 
fever, typhoid, 72, 80 
meningitis, 338 
pneumonia, 416 
varicella, 226 
Fluxes, 51, 638 
definition, 633 
treatment, 641 
Fomentations. 

duodeno-hepatitis, 533 
peritonitis, 579, 580 
perityphlitis, 546 
Food. 

cholera morbus 660 
definition, 33 
fever, typhoid, 113 
indirect, 34 
Forbes, John. 

action of medicine, 45 
Ford, W. H. 

fever, yellow, 140 
Forrey, Samuel. 

chronic general diseases, 253 
inflammation of mucous membrane of 
air passages, 372 
■ pneumonia, 416, 417, 418 



INDEX. 



883 



Forbes, Murray. 

gout, 306 * 
Fothergiil, John. 

erysipelas, 163 

Fox, Wilson. 

pneumonia, 434 
Frank. 

bronchitis, 393 
Eraser. 

tetanus, 775 
Frierich. 

fever, 60 
Fungus. 

fever, relapsing, 133 



GALEN, 
fevers, 53 
Galium. 

dropsies, 683 

epilepsy, 736 
Gallup, Joseph A. 

. cerebro- spinal meningitis, 349, 350 

meningitis, 342 

pneumonia, 416 
Galvanism. 

diabetes mellitus, 859 
Garrod. 

gout, 306 
Gastritis. 

acute and chronic, 512 

anatomical changes, 518 

diagnosis, 519 

follicular inflammation, 514 

prognosis, 520 

symptoms, 512 

treatment, 520 

ulcer, 516 
Gastrodinia, 842 
Gaultheria. 

cholera morbus. 658 

fever, typhoid, 116 
Gavarett, M. 

fever, typhoid, 97 
Gelsemmum. 

aneurism, 834 

carcinoma, 285 

cerebro-spinal meningitis, 352 

cholera, epidemic, 674 

chorea, 745 

endocarditis, 486 

epilepsy, 733 

fever, yellow, 150 

gastritis, 521 

meningitis, 352 

myocarditis, 486 

pleuritis, 444 
General Diseases. 

definition, 49 
Geranium Maculatum. 

gastritis, 525 
Gerhard. 

fever, typhus, 122 
G e;ms, 

a.ath ma, 415 

diphtheria, 166 



Germs. 

erysipelas, 154, 160 

fevers, eruptive, 205 

fever, periodical, 181 

fever, relapsing, 133 

fever, yellow, 143 

pertussis, 243 

rubeola, 237 
Ghent. 

fever, pernicious, 202 
Gill, H. Z. 

laryngo-tracheitis, 391 
Glasgow, W. C. 

bronchitis, 399, 402 
Glossitis, 505 
Glycerina. 

diabetes mellitus, 858 

enuresis, 861 

erysipelas, 162 

gastritis, 521 

stomatitis, 502 
Glycyrrhiza. 

bronchitis, 406 

duodeno- hepatitis, 533 

phthisis pulmonalis. 469 

pneumonia, 428, 429 
Goitre, Exophthalmic, 829 

causes, 830 

pathology, 830 

symptoms, 829 

treatment, 829 
Good, John Mason. 

nosology, 48 
Goumoeus. 

bronchitis, 399 
Gout, 302; causes, 302 

diagnosis, 307 

history, 302 

morbid anatomy, 306 

prognosis, 307 

symptoms, 303. 

symptoms of ciironic, 304 

treatment, 307 
Graves. 

fever, relapsing, 132 
Greenhow. 

Addison's Disease, 276, 277 
Griesinger. 

fever, relapsing, 132 

leucocythemia, 
Grindelia Robusta. 

asthma, 413, 415 

bronchitis, 408 

laryngismus stridulus, 819 
Guaicum. 

exophthalmic goitre, 831 
Gum Arabic. 

nephritis, 614 



HEMATOMA, 
pachymeningitis, 325 
Hahnemann. 

theory of disease, 24 
Hale, Enoch. 

fever, typhus, 12f 



884 



INDEX. 



Hall, Charles. 

erysipelas, 154, 155 
Hall, Marshall, 731 
Haller, 14 
Hamilton, F. H. 

fever, remittent, 189 
Hammond, W. A. 

alcohol, 864, 868 

epilepsy, 737 

meningitis, 338 

rubeola, 238 
Hartshorne, Henry. 

fever, yellow, 139 

varicella, 226 
Helmholtz. 

asthma, 415 
Hemiplegia, 715 

anatomical changes, 718 

diagnosis, 719 

prognosis, 719 

symptoms,. 715 

treatment, 720 
Hemorrhages, 685 

causes, 685 

consequences, 688 

pathology, 692 

treatment, 692 

varieties, 685 
Hepatitis, 589 

anatominal changes, 599 

diagnosis, 600 

prognosis, 600 

symptoms, 590 

treatment, 601 
Hepatitis, Duodeno, 52$ 
Hertz. 

fever, pernicious, 197, 199* 
Hippocrates. 

fever, 53" 
Hirsch. 

erysipelas, 154 

fever, typhus, 123 
Hodgkin. 

pseud o-teucoeythemia, 175 
Hodgkin r s Disease, 273 
Hoffman. 

fever, 53 

fever, typhoid, 96 

theory of disease, 23 
Holland, J. W. 

spinal meningitis, chronic, 366 
Holmes, O. W., 32 

action of medicines, 45 
Hoag, Martin. 

cholera, epidemic, 661 
Hosack, David. 

fever, yellow, 149 
Hubbard. 

laryngo- tracheitis, 391 
Hueter. 

diphtheria, 166 
Huguenin. 

pachymeningitis, 323, 325 
Humulus Lupulus. 

cerebro-spinal meningitis, epidemic, 
354 



Hamulus Lupulu*. 

chronic general diseases, 256 

diphtheria, 176 

laryngo- tracheitis, 389 

phthisis, 466 

rubeola, 240 
Hunt, Sandford B. 

erysipelas, 154 
Hunter, John. 

vaccinia, 220 
Huntington. 

cerebro-spinal meningitis, epidemic, 
350 
Heister, J. P. 

scarlatina, 233 
Huxley, Thomas, 15 
Hydrargyri Chloridum Corrosivum. 

carcinoma, 283 

duodeno-hepatitis, 533 

fever, typhoid, 103 

hepatitis, 601, 602 

hydrophobia, 780, 782 

leucocythemia, 272 

laryngo-tracheitis, 388, 3S9 

meningitis, 337 

nephritis, 627 

scrofulous inflammation of mucous 
membranes, 262 

scrofulous periostitis, 266, 267 

spinal meningitis, chronic, 367 

syphilis, 289 _ 
Hydrargyri Chloridum Mite. 

apoplexy, 709 

bronchitis, 405, 4OT 

cerebro-spinal meningitis, epidemic, 
350, : 52 

cholera, epidemic, 670, 676 

cholera morbus, 657 

colic, bilious, 549 

dengue, 77 

diabetes mellitus, 858 

diphtheria, 173 174, 176 

duodeno-hppatitis, 533 

dysentery, 563, 566 

enteritis , 538 

erysipelas, 160 

fever, intermittent, 192 

fever, pernicious, 200 

fever, remittent, 192 

fever, simple, continued, 68 

fever, typhoid, 103, 116 

fever, yellow, 150 

gastritis, 520, 522 

gout, 308 

influenza, 73 

meningitis. 336 _ 

parasites, intestinal, 846 

peritonitis, 

pertussis, 246 

pleuritis, 444, 447 

pneumonia, 429 

rheumatism. 299, 300 

scarlatina, 233 

spinal meningitis, 358 

syphilis, 289 

variola, 217, 218 



INDEX. 



885 



Hydrargyrum Cum Creta. 

cholera morbus, 659 
Hydrarjryri [odidnm Rubrura. 

periostitis, scrofulous, 206 
Hydrargyri [odidnm Viride. 

periostitis, scrofulous, 266 
Hydrargyri Oleas. 

peritonitis, 588 
Hydrargyri Oxidum Rubrura. 

periostitis, scrofulous, 267 
Hydrargyri Pilula, 

apoplexy, 711 

asthma, 408 

cholera, epidemic, 673 

constipation, 840, 841 

exophthalmic goitre, 831 

fever, remittent, 191 

gastritis, 522, 523 

gout, 308 

hepatitis, 602. 

inflammation of mucous membrane of 
nose, 380 

phthisis, 466 

spinal meningitis, 358 
Hydrargyri Subsulphas Flavus. 

diphtheria, 176 

laryngo-tracheitis, 389 
Hydrargyri Unguentum. 

syphilis, 290 
Hydrogen Peroxide. 

diabetes mellitus, 859 
Hydrophobia, 776 

anatomical changes, 779 

causes, 776 

prognosis, 779 

prophylaxis, 780 

symptoms, 778 

treatment, 779 
Hyoscyamus. 

apoplexy, 711 

bronchitis, 408 

constipation, 837 

dysentery, 65, 570 

endocarditis, 485 

fever, intermittent, 194 

fever, remittent, 194 

fever, typhoid, 117, 119, 121 

gastritis, 322, 323, 324, 325 

gout, 308, 309 

indigestion, 840, 841, 

inflammation, mucous membrane of 
nose, 380 

meningitis, 336 

mental derangements, 806 

myocarditis, 485 

nephritis, 626 

paraplegia, 722 

peritonitis, 588 

phthisis, 466 

spinal meningitis, chronic, 367 

tetanus, 774 

terrors, night, 766 
Hysteria, 755 

causes, 756 

diagnosis, 757 

paihology, 757 



Hysteria. 

prognosis, 758 

symptoms, 756 

treatment, 759 

varieties, 755 
Hystero-epilepsy, 762 
Hypophosphites. 

adenitis, 262 

ccrebro-spinal meningitis, epidemic, 
354, 355 

chorea, 745 

convulsions, 755 

leucocythemia, 273 

rubeola, 240 

spinal meningitis, 358 

spinal meningitis, chronic, 367, 369 

stomatitis, scorbutic, 502 



TCE. 

1 cerebro-spinal meningitis, 352 
cholera, epidemic, 675 
enteritis, 539 
gastritis, 520 
hemorrhages, 694 
peritonitis, 
Incisions. 

perityphlitis, 547 
Indigestion, 835 
Infection, definition, 63 
Inflammation, 313 

essential pathology, 313 

gangrene, 318 

results, 316 

treatment, 319 

aorta, 487 

genito- urinary organs, 608 

cesophagus, 510 

mucous membranes, 

scrofulous, 262 

pancreas, 607 

respiratory organs, 369, 371 

age, 371 

c.imatic conditions, 372 

etiology, 371 

exciting causes, 374 

habits, personal, 372 

occupation, 371 

symptomatology, 374 
nasal passages, 

a^ube, 374 

chronic, 376 

diagnosis, 378 

prognosis, 378 

treatment, 378 
Influenza, 69 

diagnosis, 72 
etiology, 71 
history, 69 
pathology, 71 
prognosis, 71 
symptoms, 70 
treatment, 72 
Insomnia, 762 

treatment, 763 
varieties, 762 



886 



INDEX. 



Instruments, *3 
Iodides. 

cerebro-spinal meningitis, 352 
lodinum. 

adenitis, 262 

diphtheria, 172, 173, 174 

duodeno-hepatitis, 534 

erysipelas, 162 

fever, typhoid, 103, 118 

fever, typho-iualarial, 204 

gastritis, 523 

inflammation mucous membrane, 
nose, 380 

laryn go- tracheitis, 390 

nephritis, 601 

periostitis, scrofulous, 266, 267 

peritonitis, 588 

plague, 131 

scarlatina, 233 

syphilis, 290 
Iodoforrnum. 

laryngo-tracheitis, 302 

syphilis, 288 
Ipecacuanha. 

dysentery, 561, 568, 570, 571 

enteritis, 538, 540 

gastrodinia, 843 

laryngismus stridulus, 819 

laryngo-tracheitis, 390 
Ipecacuanha? Pulv. Comp. 

influenza > 73 



TABORANDI. 

J diabetes mellitus, 859 

fluxes, 642 

gout, 307 

nephritis, 616, 628 
Jaccoud. 

leucocythemia, 268 
Jackson, James. 

carcinoma, 283 

epilepsy, 734 

fever, typhoid, 92 
Jackson, Samuel. 

elementary properties, 15 
Jalapa. 

colic, bilious, 549 

meningitis, 336 

nephritis, 628 
Jenner, Edward. 

vaccinia, 220, 221, 224 
Jenner, Sir William. 

fever, 35 

fever, eruptive, 205 

fever, relapsing, 132 

fever, typhoid, 122, 126 
Jewell, J. S. 

cerebro-spinal meningitis, 347 
Jones, Bence. 

fever, typhoid, 98 
Jones, Joseph. 

diabetes mellitus, 859 

fever, typhoid, 98 



KAMEELA. 
parasites, intestinal, 848 
Kane, W. M. 

tetanus, 775 
Klebs. 

fever, periodical, 181 

fever, typhoid, 83 
Klein. 

fever, typhoid, 83 
Koosso. 

parasites, intestinal, 848 



T ACTOPHOSPHATES. 
Li convulsions, 755 
Laennec. 

bronchitis, 393 
Lallemand. 

alcohol, 864, 868 ' 
Laryngismus stridulus, 817 
Laryngo-tracheitis, acute, 381 

causes, 382 

pathological anatomy, 382 

symptoms, 383 

varieties, 382 
Laryngo-tracheitis, chronic, 386 

diagnosis, 387 

pathological anatomy, 387 

prognosis, 387 

symptoms, 386 

treatment, 388 
Laxatives. 

apoplexy, 709 

bronchitis, 405, 407 

diphtheria, 174 

dysentery, 561, 562 

erysipelas, 160 

fever, typhus, 127 

hepatitis, 601, 602 

inflammation, 320 

inflammation of mucous membrane of 
nose, 378 

laryngo-tracheitis, 388 

pleuritis, 446 

rheumatism, 298, 300 

rubeola, 240 

stomatitis, 490 

variola, 217 
Lebert. 

anaemia, pernicious, 275 

fever, relapsing, 133, 137 

fever, typhus, 126 
Leeches. 

apoplexy, 709 

bronchitis, 404, 406 

gastritis, 520 

glossitis, 509 

nephritis, 615 

peritonitis, 579 

perityphlitis. 546 

sunstroke, 788 
Letulle. 

Addison's disease, 276 
Lemert. 

alcohol, 862 



INDEX. 



887 



LeRoche, R. 

fever, yellow, 143, 145 
Leococythemia, 267 

causes, 2 
diagnosis, 270 

history, 267 

morbid anatomy, 269 

prognosis, 272 

special pathology, 270 

symptoms, 

treatment, 272 
Liebiar. 

alcohol. 863 

bodily heat, 53 

foods', 29 
Liebermeister. 

fever, typhoid, 82, 90, 92 

plague, 12S 
Lime, Quick. 

diphtheria. 176 
Linimentum Saponis Camph. 

aden tis. _ 

mumps. 248 

peritonitis, 588 

scarlatina, 234 

spinal meniugitis, 367 

syphilis, 290 
Lithii Bromidum. 

apoplexy. 713 

asthma, 413 

epilepsv. 736 

gout, 307, 308, 309 

laryngo- tracheitis, 390 

meningitis, 338 
Lithii Cabonas. 

gous 307 
Lithii Citras, 

gout, 307, 308 
Lisfranc, M. 

laivngo-tracheitis, 392 
Littlefield. 

cerebro-spinal meningitis, 350 
Lobelia. 

laryngismus stridulus, 318 

roseola, 246 
Local Diseases, 49 
Locke, John. 

mental derangements, 793 
Louis. M. 

fever, typhoid, 77, 85, 90 

fever, typhus, 122, 126 
Lupulin. 

bronchitis, 408 

gastritis, 523 



MACKENZIE, 
fever, relapsing, 132 
Macrobius. 

diphtheria, 163 
Magnesii Carbonas. 

constipation, 842 
Magnesii Citras. 

cerebro-spinal meningitis, 352 

duodeno-hepatitis, 532 

erysipelas, 615 



Magnesii Hyposolphu. 

fever, er >ptive, 210 
Magnesii Bnlpnas. 

cholera, epidemic, 673 

duodeno-hepatitis, 532 

dysentery. 564, 566 

enteritis, 539, 540 

ervsipelas. 615 

ievev, typhoid, 117, 113 

meningitis, 336 

spinal meningitis, 353 
Magnesii Sulphis. 

fevers, eruptive, 210 

fever, intermittent, 193 

fever, remittent, 193 
Magnetism-Electro. 

diabetes mellitus, 859 
Malone, G. B. 

fever, pernicious, 203 
Malt Extract. 

adenitis, 262, 369 

spinal meningitis, chronic, 
Manassein. 

fever, relapsing, 133 
Manna. . 

stomatitis, 492 
Martin, H. A. 

vaccinia, 223 
Martin. 

alcohol, 865 
Massage. 

epilepsy. 755 

spinal meningitis, 358 
Mcintosh. 

fever, periodical, 191 
McNaaghten, James. 

fever, tvphoid, 92 
Measles, 237 

nephritis, 610 
Medical Theories, 23 
Medicines. 

classification, 34 

definition, 33 

method of introduction, 34 
Meeker, D. 

erysipelas, 154 
Meigs," J. F. 

fever, 60 
Melasma Suprarenalis, 276 
Meningitis, 325 

causes, 325 

diagnosis, 333 

pathology, 331 

prognosis, 334 

scrofulous, 327 

symp:oms. 325 

treatment, 334 

tuberculous, 327 
Meningitis, cerebro-spinal, 359 

diagnosis, 340 

prognosis, 340 

symptoms, 339 

treatment, 340 
Meningitis, cerebro-spinal, epidemic, 341 

causes, 342 

diagnosis, 348 



888 



INDEX. 



Meningitis, cerebrospinal, epidemic, 
history, 341 
morbid anatomy, 347 
prognosis, 348 
symptoms, 345 
treatment. 350 
Meningitis, spinal, 355 
diagnosis, 357 
etiology, 355 
morbid anatomy, 357 
prognosis, 357 
symptoms, 356 
treatment, 357 
Meningitis, spinal, chronic, 361 
diagnosis, 365 
morbid anatomy, 364 
prognosis, 365 
symptoms, 361 
treatment, 366 
Miasms, 38 . 

definition, 64 
Michel, R. F. 

fever, pernicious, 202 
Miguet, 491 
Miner. 

cerebro-spinal meningitis, epidemic, 
350 
Mint, indigestion, 842 
Miscellaneous diseases, 810 

varieties, 810 
Mitchell, J. K. 

arthritis deformans, 311 
fever, periodical, 181 
influenza, 71 
miasms, 38 
Myelitis, 359 

diagnosis, 359 
pathological anatomy, 360 
prognosis, 360 
svmptoms, 359 
treatment, 360 
Marcy, H. O. 

hydrophobia, 780 
Morgagni. 

cholera, epidemic, 661 
Morphia? Acetas. 

cholera, epidemic, 674 
cholera morbus, 658 
dysentery, 566, 567 
Morphia? Sulphas. 

angina pectoris, 827 
asthma, 413 
bronchitis, 4 n 6 
cholera, epidemic, 673, 674 
cholera morbus, 657, 659 
colic, bilious, 548 
delirium tremens, 795 
dysentery, 568 
fever, intermittent, 191 
fever, pernicious, 201 
fever, remittent, 191 
fever, tvphoid, 122 
fluxes, 644 
heat exhaustion, 789 
meningitis, cerebro-spinal, epidemic, 
351 



Morphia? Sulphas, 
neuralgia, 763 
peritonitis, 578, 579, 580 
phthisis pulraonalis, 469 
pleuritis, 444, 447, 469 
pneumonia, 429 
tetanus, 77-3 
Morton. 

cholera, epidemic, 661 
Mott, Valentine. 

action of hydrargyri chloridum cor- 
rossivum, 103 
Mtiller. 

on fibrine, 12 
Mumps, 247 

diagnosis, 248 
prognosis, 248 
symptoms, 247 
treatment, 248 
Murchison. 
fever, 59 

fever, typhoid, 92 
fever, typhus, 126 
Musk. 

roseola, 246 
Mustard. 

cholera, epidemic, 675 



\TARCOTICS, 35 
^\ convulsions, 755 
Nasse. 

fibrine, 12 
Nature. 

definition, 31 
Nauman. 

pseudo-leucocythemia, 273 
Neil, John. 

cholera, epidemic, 668 
Nephritis, 608 

anatomical changes, 613 

causes, 608 

diagnosis, 609, 613 

prognosis, 614 

symptoms, 610 

treatment, 614 
Nephritis, chronic, 619 

anatomical changes, 623 

causes, 619 

diagnosis, 624 

prognosis, 625 

symptoms, 620 

treatment, 625 
Nephritis, Suppurative, 630 

anatomical changes, 635 

causes, 630 

diagnosis, 635 

prognosis, 636 

symptoms, 631 

treatment, 637 
Neuralgia. 766 

diagnosis, 767 

palhologv, 768 

treatment, 768 

varieties, 766 



INDEX. 



88<J 



Near 

pathology, 

physiology, 694 
Nox Von i 

apoplexy, 711 

enok ra epidemic, 673 

constipation, 840 

enuresis, 961 

fever, periodical, 194 

phthisis pulmonale, 466 
Nutrition, 35 

conditions, 26 



O'BRIEN, 
lever, relapsing, 132 
Oenothera Biennis. 

bronchitis, 408 
Oleum Morrhuae, 103 

adenitis, 262 

bronchitis, 408 

diphtheria, 175 

phthisis pulmonalis, 465, 466, 469 

pneumonia, 436 

rubeola, 240 

scarlatina, 234 

syphilis. 290 
Oleum Oliv0e. 

diphtheria, 174. 
Oleum Tiglii. 

dvodeno-hepatitis, 534 

gastritis, 523 

hepatitis, 601 

laryngo-tracheitis, 392 
Opiates. 

convulsions. 755 

insomnia, 764 

paraplegia, 222 
Opium. 

angina pectoris, 828 

bronchitis, 406, 407, 409 

carcinoma, 285 

cerebro-spinal meningitis, 250, 3-54 

cholera, epidemic, 673, 674 

cholera morbus, 656, 657, 658, 659 

constipation, 841 

dengue, 77 

diabetes mellitus, 858, 859 

diphtheria, 176 

dysenterv, 562, 563, 564, 565, 566, 
567, 570, 571 

enteritis, 538, 539, 540, 541 

ervsipelas, 161 

fever, typhoid, 116, 118 

fever, relapsing, 137, 138 

fever, simple continued, 73 

fever, yellow, 150, 151 

gastritis. 521, 522 

gout, 307, 308 

inflammation mucous membrane of 
nose, 381 

laryngismus stridulus, 818 

laryngo- tracheitis, 388 

peritonitis, 578, 579 

pleuritis, 444, 445, 446, 448 

pneumonia, 401, 437 



Opium. 

roseola, 216 
rubeola, 240 

stomatitis xorbutic, 502 

tetanus, 77J 

trichina-. - 

variola, 218 
Organized matter, properties of, 14 

structures, varieties of, 14 

functions, 15, 17 

primary morbid conditions, 19, 22 

hi notions, morbid conditions of, 22 
Oertel. 

diphtheria, 166, 173 
Osborne. 

fever, pernicious, 202 
Obermeir. 

fever, relapsing, 133 
Ozena, 377 



PACHYMENINGITIS, 322 
diagnosis, 324 

pathological changes, 324 

prognosis, 325 

treatment, 325 
Paget. 

fibrine, 12 
Paine. Martyn. 

elementary properties, 15 

theory of disease, 23 
Palmer, A. B. 

pneumonia, 434 
Palpitation, 42 
Paralysis, 714 

varieties, 714 
Paraplegia, 720 

prognosis, 722 

treatment, 722 

varieties, 720 
Park, Roswell. 

rotheln, 241 
Parker, Willard. 

carcinoma, 283 

nephritis. 627 

perityphlitis, 547 
Parkes. 

alcohol. 865 

fever, 53, 59 
Peacock, T. B. 

bronchitis, 398. 
Pepper, Wm. 

"Addison's disease, 277 

aneemia, pernicious, 275 
Pepper, Cayenne. 

scarlatina, 234 
Pepsina. 

constipation, 838 

diabetes mellitus, 859 
Percy. 

alcohol, 863, 864 
Pericarditis, 471 

diagnosis, 476 

pathological changes, 474 

prognosis, 476 

symptoms, 472 



89a 



INDEX. 



Pericard'tis. 

treatment, 476 
Periodical fever, 173 
Peritonitis, 572 
acute, 573 

anatomical changes, 575 
diagnosis, 576 
prognosis, 577 
symptoms, 5 3 
treatment, 578 
chronic, 581 

prognosis, 586 
symptoms, 582 
treatment, 588 
nephritis, 629 
Perityphlitis, 543 
symptoms, 543 
treatment, 545 
Pernicious fever, 182, 196 
Perrin, M. 

alcohol, 864, 866 
Peter. 

diphtheria, 166 
Peters, J. C 

cholera, epidemic, 665 
Phlegmasia, 50 
Phloridzin. 

cholera morbus, 659 
Phosphorus. 

meningitis, 338 
Phthisis. 

fibroid, 434 
pulmonalis, 450 

anatomical changes, 459 
diagnosis, 461 
prognosis, 463 
symptoms, 452 
treatment, 46i 
Physic, Philip Syng. 
varieties, 450 
fever, yellow, 149 
Physostigma. 

cerebro-spinal meningitis, epidemic, 

352, 354 
epilepsy, 733 
hydrophobia, 780 
spinal meningitis, 358 
tetanus, 774 
Phytolaccae Decandra. 
bronchitis, 407 
meningitis, 338 
rheumatism, 299 
spinal meningitis, chronic, 367 
Pilocarpin. 

bronchitis, 407 
diabetes mellitus, 852, 859' 
fluxes, 642 
influenza, 74 
nephritis, 616, 617, 623 
Pine, Oil of Scotch, 
bronchitis, 409 
inflammation, mucous membrane of 

nose, 381 
pneumonia, 437 
Plague, 128 
causes, 128 



Plaerue. 

diagnosis, 129 

history, 128 

pathology, 130 

prognosis, 130 

prophylaxis, 131 

symptoms, 129 

treatment, 130 
Pleuritis, 437 

diagnosis, 443 

history, 437 

nephritis, 629 

pathological anatomy, 442 

prognosis, 442 

symptoms, acute, 438 

symptoms, chronic, 441 

treatment, 443 
Plumbi Acetas. 

cholera, epidemic, 674 

cholera morbus, 657, 658 

dysentery, 565, 566, 567 

erysipelas, 162 

fever, ty. hoid, 119 

gastritis, 525 

hemorrhages, 693 
Pneumonia, acute, 416 

age, 419 

catarrhal, 423 

diagnosis, 424 

disseminated, 423 

etiology, 416 

exciting causes, 419 

history, 416 

interstitial, 416 

lobar, 416 

lobular, 416, 423 

malarial influences, 421 

occupation, 418 

pathological anatomy, 424 

previous condition, 419 

prognosis, 424 

rheumatic influences, 422 

seasons, 418 

sex, 419 

symptoms, 420 

typhoid influences, 422 

treatment, 426 
Pneumonia, chronic, 432 

prognosis, 435 

symptoms, 435 

treatment, 436 
Podagra. 

arthritis deformans, 302 
Podophyllum. 

hepatitis, 602 
Pomegranate. 

parasites, intestinal, 848 
Potassii Acetas. 

cholera morbus, 658 

dropsies, 683 

fever, relapsing, 138 

fever, typhoid, 118 

rheumatism, 299 
Potassii Arsenias. 

carcinoma, 285 

chorea, 744 



INDEX. 



891 



Potassii A.rsenias. 

fever, periodical, 102 
Potassii Bicarbonas. 

arthritis deformans, S07 

bronchitis, 407 

rheumatism, 298 
Potassii Bitartras, 

dropsies, 683 

inflammation mucous membrane of 
nose, 378 

nephritis, 614, 616, 618, 626, 627, 
628 

pericarditis, 477 

roseola, 243 

varicella, 226 
Potassii Bromidum. 

apoplexy, 711 

asthma, 413, 415 

bronchitis, 405 

constipation, 837 

delirium tremens, 794 

dysentery, 571 

enteritis, 542 

epilepsy, 737 

fever, periodical, 122 

influenza, 73 

insomnia, 764 

meningitis, 338 

mental derangements, 806 

mumps, 248 

roseola, 240 

rubeola, 240 
Potassii Carbonas. 

rheumatism, 298 
Potas.ii Chloras. 

aneurisms, 854 

diphtheria. 172 

fatty degeneration of heart, 833 

fever, typhoid, 101, 102, 116 

glossitis, 506 

laryn go- tracheitis, 390 

pneumonia, 431 

scarlatina, 233, 234, 235 

stomatitis, 496, 500 

tonsilitis, 509 
Potassii Chloridum. 

diphtheria, 174 
Potassii Iodidum. 

adenitis, 262 

aneurisms, 854 

apoplexy, 709 

asthma, 413 

bronchitis, 408 

cerebro-spinal meningitis, epidemic, 
355 

diabetes, 851 

dropsies, 683 

endocarditis, 484 

fever, typhoid, 106, 118 

glossitis, 506 

laryngo-tracheitis, 389 

meningitis, 336 

myocarditis, 484 

paraplegia, 722 

periostitis, scrofulous, 266 

peritonitis, 581, 588 



Potassii [odidum. 
plague, 181 
pleuritis, 446 

pneumonia, chronic, 436 

rheumatism, 299 

roseola, 242 

spinal meningitis, 358 

stomatitis, 510 
Potassii Nitras. 

asthma, 415 

cholera, epidemic, 676 

diabetes, 851 

dropsies, 683 

duodeno-hepatitis, 533 

dysentery, 563 

erysipelas, 160 

fever, simple continued, 68 

fever, typhoid, 116. 

influenza, 73 

laryngo-tracheitis, 389, 390 

nephritis, 616, 617, 618, 626 

pleuritis, 448 
Potassii Permanganas. 

diphtheria, 172, 176 

inflammation, mucous membrane of 
nose, 381 

periostitis, scrofulous, 266 

scarlatina, 233 

stomatitis 495, 496, 502 
Potassii Salicylas. 

gout, 308 
Poultice. ^ 

phthisis pulmonalis, 468 

pneumonia, 428 

syphilis, 289 
Prout. 

alcohol, 863, 864 
Prunus Virginiana. 

bronchitis, 406 
Pseudo-leucocythemia, 273 
Pumpkin Seeds. 

parasites, intestinal, 848 
Purgatives. 

apoplexy, 709 

cerebro-spinal meningitis, epidemic, 
350 
Purtussis, 213 

causes, 243 

diagnosis, 243 

prognosis, 245 

sequela3, 247 

special pathology, 245 

symptoms, 244 

treatment, 246 



QUINI-E CITRAS. 
fever, relapsing, 138 
Quinise Sulphas, 
asthma, 413 

bronchitis, 405, 406, 407, 408 _ 
cerebro-spinal meningitis, epidemic, 

350,351,353,354 
cho'era, epidemic, 673 
dengue, 76 



892 



INDEX. 



Quinise Sulphas. 

diphtheria, 175, 177 

dysentery, 506 

erysipelas, 161 

fever, pernicious, 193, 202 

fever, periodical, 192, 193, 194 

fever, relapsing, 137 

fever, typhoid, 115 

fever, typho-malarial, 204 

fever, yellow, 149, 151 

gout, 309 

hysteria, 761 

inflammation mucous membrane of 
nose, 379 

influenza, 73, 74 

laryngo-tracheitis, 389, 390 

leucocythemia, 272 

neuralgia, 669 

phthisis, 469 

pneumonia, 429, 430, 431 

rheumatism, 299 

roseola, 243, 246 

scarlatina, 237 

spinal meningitis, 358 

stomatitis, 502 

sunstroke, 790 

tonsilitis, 509, 510 

variola, 217 
Quinise Tannas. 

cholera morbus, 659 



KOTHELN, 241 
causes, 241 

diagnosis, 242 

history, 241 

prognosis, 242 

symptoms, 241 

treatment, 242 
Rattlera. 

parasites, intestinal, 848 
Recklinghausen. 

inflammation, 319 

typhoid, 83 
Recto-colitis, 551 
Remedial Agents. 

definition, 33 
Rennet. 

diabetes mellitus, 859 
Revnolds. 

* rubeola, 237 
Rhatany. 

gastritis, 525 
Rheumatism, 291. 

acute articular. 292 

chronic, 295 

clinical history, 292 

diagnosis, 296 

etiology, 291 

pathology 297 

prognosis, 296 

sub-acute, 294 

treatment, 297 

varieties, 291 
Rhubarb. 

intestinal parasites, 846 



Rhus Aromatica. 

enuresis, 861 
Richardson, B. W. 

alcohol, 864 
Richardson, J. G. 

fever, yellow, 149 
Ringer, Sidney. 

alcohol, 865 
Robin, M. 

fibrin, 13 
Rochelle Salts.^ 

cerebro-spinal meningitis, 352 

duodeno- hepatitis, 532 

enteritis, 539 

gout, 308 

nephritis, 615 
Roseola, 242 

clinical history, 242 

treatment, 243 
Rubeola, 237 

causes, 237 

diagnosis, 239 

history, 237 

pathological anatomy, 239, 

prognosis, 239 

sequelae, 240 

symptoms, 238 

treatment, 239 
Rush, Benjamin. 

dengue, 74 

fever, yellow, 143, 149 

gout, 303 

theory of disease, 23 



QAGE. 

O thrush, 493 

Sainsbury, Harrington. 

alcohol, 865 
Salisbury, J. H. 

influenza, 71 

fever, periodical, 181 

rubeola, 238 
Salix Alba. 

fever, periodical, 192, 194 
Sanderson, Burdon. 

diphtheria, 166 
Sandras. M. 

alcohol, 864 
Sanguinaria._ 

bronchitis, 405 

laryngo-tracheitis, 389 

laryngismus stridulus, 819 

pneumonia, 428 

roseola, 246 

rubeola, 240 
Santonin 

intestinal parasites, 846 
Sarsaparilla. 

nephritis, 626 
Satterthwaite. 

diphtheria, 156 
Scarification. 

laryngo-trache.tis, 391 
Scarlatina, 227 

complications, 232 



INDEX. 



893 



Searlat'na. 

diagnosis 290 

history, 227 

pathology, 231 
prophylaxis, 235 
prognosis, 280 
sequela, 235 

symptoms, 228 
treatment, 232 
Schmidt, C. 

fever, yellow, 147 

cholera, epidemic, 668 
Seilla. 

bronchitis, 405, 407 

diphtheria, 176 

influenza, 73 

laryngismus stridulus, 818 

laryngo-tracheitis, 388 

roseola, 246 

rubeola, 240 
Sclerosis, Cerebral, 330 
Scrofula, 258 
Scutellaria. 

aphonia, 822 

endocarditis, 486 

exophthalmic goitre, 831 

cardiac irritability, 828 

fluxes, 643 

gastritis, 522 

hysteria, 760 

myocarditis, 486 
Secretions. 

classification, 12 
Sedatives. 

cerebro spinal meningitis, 353 

general, 35 

pneumonia, 428 

meningitis, 335, 336 

nervous, 36 

vascular, 36 
Seguin, E. 

meningitis, 362 
Senecio Aureus. 

rheumatism, 299 

meningitis, 367 
Senega. 

bronchitis, 405 

influenza, 73 
Senna. 

parasites, intestinal, 845, 846 
Setzench. 

pertussis, 243 
Shonbein. 

influenza, 71 
Simmers, D. B. 

rubeola, 237 
Simon, M. 

fibrine, 13 
Simons, T. G. 

bronchitis, 399 
Sinapism. 

angina pectoris, 828 

apoplexy, 710 

cerebro-spinal meningitis, 350 

convulsions, 753 

fever, relapsing, 138 



Sinapism. 

Fever, yellow. 150 

hysteria, 760 

tetanus, 775 

variola, 217 
Smith, J. L. 

rotheln, 241 
Smith, J. M. 

diphtheria, 164 

fevei, typhus, 124 
Smith, B. K. 

scarlatina, 283 
Smith, Southwood. 

fever, 54 
Snow. 

cholera, epidemic, 669 
Sodii Arsenias. 

carcinoma, 284 
Sodii Bicarbonas. 

bronchitis. 407 

cerebro-spinal meningitis, 352 

cholera morbus, 657 

dengue, 77 

duodeno-hepatitis. 534 

diphtheria, 173, 176 

fever, periodical, 192 

fever, yellow, 150 

gastritis, 521, 522 

indigestion, 842 

laryngo-tracheitis, 389 

pericarditis, 447 

pleuritis, 444, 447 

rheumatism, 298, 299 

spinal meningitis, 358 

thrush, 492 
Sodii Benzoas. 

asthma, 415 

diphtheria, 172, 175 

laryngo-tracheitis, 390 

scarlatina, 233 
Sodii Boras. 

stomatitis, 490, 493 
Sodii Bromidum. 

mental derangements, 806 
Sodii Carbonas. 

rheumatism, 298, 301 
Sodii Chloras. 

diphtheria, 172 
Sodii Chloridum. 

cholera, epidemic, 675 

inflammation mucous membrane of 
nose, 381 

fever, typhoid, 102 

parasites, intestinal, 845 
Sodii Hypophosphis. 

bronchitis, 408 

diphtheria, 178 

fever, periodical, 195 

hydrophobia, 782 
Sodii Hyposulphis. 

fever, eruptive, 211 

fever, pernicious, 203 

fever, relapsing, 138 

scarlatina, 233 
Sodii Iodidum. 

bronchitis, 407, 408 



894 



INDEX. 



Sodii Iodidum. 

periostitis »5crofulous, 266 

meningitis. 337, 336 

svph'.lis, 289 
Sodi' fcaiieyias. 

bronchitis, 407 

chorea, 745 

enuresis, 861 

fever, relapsing, 137 

glossitis, 507 

gout, 308, 309 

meningitis, 338 

rheumatism, 298 

spinal meningitis, 358 

tonsilitis, 509 
Sodii Sulphis. 

diphtheria, 172 

erysipelas, 161, 163 

fever, eruptive, 210 

fever, pernicious, 203 

fever, periodical, 123 

fever, relapsing, 138 
Sodii Sulpho-Carbolas. 

diphtheria, 172 

scarlatina, 233 
Spigelia. 

parasites, intestinal, 845, 846 
Splenitis, 603 

anatomical changes, 605 

clinical history, 603 

diagnosis, 606 

prognosis, 607 

treatment, 609 
Sponging. _ 

scarlatina, 233 
Stahl, 14 
Sternberg, G. M. 

fever, periodical, 181 

hydrophobia, 780 
Stewart, A. P. 

fever, typhus, 122 
Stimulants, general, 35 
Stomatitis, 490 

folicular, 493 

materni, 497 

symptoms, 497 

treatment, 499 

mercurial, 495 

treatment, 496 

scorbutic, 5131 
Stramonium. 

arthritis deformans, 311 

asthma, 415 

chorea, 745 

epilepsy, 736 

endocarditis, 484 

meningitis, 367 

myocarditis, 484 

rheumatism, 299, 301 
Strychnia. 

bronchitis, 408 

cholera, epidemic, 673 

constipation, 841 

diphtheria, 172, 175, 177, 178 

fever, periodical, 194 

fever, p3rnicious, 202 



Strychnia. 

fever, typhoid, 100, 106, 115, 118, 
119, 120 

fever, yellow, 151 

gastritis, 523 

spinal meningitis, 358 

variola, 218 
Strychnine Citras. 

syphilis, 290 
Sudamina, 227 
Sunstroke, 783 

anatomical changes, 785 

diagnosis, 785 

prognosis, 788 

symptoms, 784 

treatment, 788 

varieties, 783 
Sutton, Geo. 

erysipelas, 154 
Sutton, W. L. 

scarlatina, 233 
Sydenham. 

scarlatina, 227 
Syphilis, constitutional, 286 

TEMPERATURE, NORMAL, 28 
J. daily variations, 29 
Terebinthina. 

bronchitis, 408 

cholera, epidemic. 673 

cholera morbus, 658 

diphtheria, 174 

dysentery, 564, 570, 571 

enteritis, 539 

erysipelas, 161 

fever, typhoid, 116, 119, 121 

fever, typhus, 127 

fever, yellow, 151 

haematuria, malarial, 203 

peritonitis, 579 

roseola, 242 

variola, 218 
Terror, Night, 765 . 
Tetanus, 770 

anatomical changes, 771 

causes, 772 

prognosis, 773 

symptoms, 770 

treatment, 774 
Theine. 

dysentery, 567 

peritonitis, 581 
Therapeutic Methods, 44 
Thomas, Louis. 

rubeola, 237 
Thompson, Samuel. 

theory of disease, 24 
Thrush, 491 
Tobacco. 

cancrum oris, 503 

colic, bilious, 550 

insomnia, 763 _ 

spinal meningitis, 366 
Todd, R. B. 

gout, 306 



1SDEX. 



8\)~j 



Tolutona. 

bronchitis, 408 
Tonsilitis, 507 
Tonics, general, 35 
Tracheotomy, 

diphtheria, 176 

laryngo-tracheitis, 391 
Trichina, 849 
Trouseau, A. 

diphtheria, 166 

leucocythemia, 268 

rubeola. 2: 57 

spinal meningitis-, 364 
Typhlitis. 542 
Tyson, James. 

diabetes mellitus, 60 



TTLCER, GASTRIC, 516 
U anatomical changes, 518 

diagnosis, 519 

prognosis, 520 

treatment, 520 
Ulmus Fiava. 

nephritis, 614 

stomatitis, 490, 500 
Upham, J. B. 

typhus, 127 
Uva Ursa. 

dropsies, 6 Q 3 

nephritis, 626 ' 



T7ACCINA, 220 
V Valeriana. 

aphonia, 822 

cardiac irritability, 824 

catalepsy, 749 

heat exhaustion^ 789 ' 

hysteria, 760 

nephritis, 615 

paraplegia, 72 3 

terrors, night, 766 
Varicella, 225 

diagnosis, 226 

symptoms, 225 

treatment, 226 
Variola, 213 

diagnosis, 216 

malignant, 218 

prognosis, 216 

symptoms, 213 

treatment, 216 
Varioloid. 

diagnosis, 219 

prognosis, 220 

prophylaxis, 220 

symptoms, 219 

treatment, 220 
Venesection, 

apoplexy, 708, 709, 712. 

bronchitis, 405 

cholera, epidemic, 675 

meningitis, 335 

nephritis, 615 

peritonitis, 578 



Venesection. 

pleuritis, 444, 448 
pneumonia, 428, 430 

Veratria 

spinal meningitis, 367 
Veratrum Viride 

aneurisms, 834 

apoplexy, 709, 713 

bronchitis, 405 

dysentery, 565 

endo-carditis, 486 

fever, eruptive, 212 

fever, periodical, 191 

fever, simple continued, 68 

fever, yellow, 150 

influenza, 73 

meningitis, 336 

myocarditis, 486 

nephritis, 614, 616 

pleuritis, 444 

rheumatism, 299 

spinai meningitis, 358 
Vinegar. 

diphtheria, 176 
Virchow. 

Addison's disease, 277 

fever, 53, 59. 

inflammation, 319 

leucocythemia, 268 

pachymeningitis, 325 

pseudo-leucocythemia, 273 



WALES, P. S._ 
cerebro-spinal meningitis, 349 
Waller. 

inflammation, 319 
Wallowiez. 

alcohol, 865 
Waterhouse, Benjamin. 

vaccina, 221 
Waters. 

Bethesda. 

diabetes mellitus, 857 
nephritis, 625 
Lime. 

gastritis, 521 
Mineral. 

diabetes insipidus, 851 
rheumatism, 301 
Watson. 

tetanus, 775 
Webster, Noah. 

epidemic and pestilential diseases, 
69 
Weigert. 

fever, relapsing, 133 
Welden, Austin. 

anaemia pernicious, 276 
Wells, Wm. L. 

diphtheria, 164 
Welsh. 

fever, relapsing, 132 
Wey, Wm. C. 

diphtheria, 165 



896 



INDEX. 



Whitmire, J. S. 

erysipelas, 162 
Willard. 

diphtheria, 164 
Wilks, Samuel. 

Addison's disease, 276 
Williams, C. J. B. 

elementary properties, 15 

fibrin, 12 
Williamson, Hugh. 

spinal meningitis, 341 
Wood, Geo. B. 

fever, 53, 54 

fever, typhoid, 78, 92 
Wood,H. C. 

diphtheria, 166 
Woodward, J. J. 

rubeola, 238 
Wragg, W. T. 

dengue, 75, 74 
Wright, N. 

fever, periodical, 191 
Wunderlach. 

fever, 59 
Wyman, Morrell. 

asthma, 415 



ELLOW DOCK. 
nephritis, 627 



ZIEMSSEN. 
fever, simple continued, 65 
Zimmerman. 

fibrin, 12 
Zinci Oxidum. 

fluxes, 643 

gastritis, 523 
Zinci Phosphidum. 

spinal meningitis, 367 
Zinci Sulphas. 

diphtheria, 176 

epilepsy, 732 

inflammation mucous membrane of 
nose, 379, 380 

laryngo-tracheitis, 390 

stomatitis, 495, 502 
Zinci Valerianas. 

chorea, 744 

epilepsy, 636 
Zuelzer. 

erysipelas, 154 



c 



If 



